Order

1 Delivery Date

Order Date: 03/30/2015

2 Prescriber Information

(For example: Acme Hospital)

(For example: PT Dept.)

Last Name:

Ext:

3 Patient Information

Sex:

Apt #:

State:

Tel:

WT (LBS.):

Medicaid#:

Other Insurance Name:

Other Insurance No.:

Other Insurance Ph. No.:

Diagnosis:

4Doctor Information

City:

Zip:

Ambulatory Aids

Standard Wheelchair for Patients that CANNOT Self-Propel
Standard Wheelchair for Patients that CAN Self-Propel

Motorized Wheelchair

Standard Walker
Walker With Wheels

Rollator

Quad Cane - Large
Quad Cane - Small
Standard

Bath Safety

Commode

Raised Toilet Seat

Transfer Bench

Bath seat

Tub Rail
Grab Bar

Bedroom Accessories Diabetic and Nutrition

Semi-electric Hospital Bed with Gel Overlay
Hospital Bed Only
Gel Overlay Only
Air Mattress

Over-bed Table

Patient Lift

Diabetic Supplies
Monitor
Test Strips
Lancets
Alcohol Wipes

Nutritionals
Ensure
Ensure Plus
Pediasure
Glucerna
Boost
Other

Incontinence Respiratory

Diapers
Small
Medium
Large
X-Large
Chux
Cloth Chux
Incontinence Liners
Gloves
Cloth Chux
Incontinence Liners

Nebulizer

Oxygen Concentrator
Oxygen Portable System
Pulse Oximeter

BIPAP
CPAP
Lancets
Heated Humidification

Nutritionals
Suction Machine
Suction Supplies

Please mail original prescription to: 5353 Kings Highway, Brooklyn, NY 11203

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