Tel: (602) 470-9700  |  (480) 893-1662  |   (623) 935-1221  
Fax:  (480) 347-0280  |  (602) 454-6306
Facility Name/Phone:
Contact Person/
Relationship/
Phone
Date:
Patient First Name:
Patient Address:
Patient City/St/Zip:
Patient Phone:
Status
Fall Risk
Height
Weight 
Case Manager/Phone:
Destination Type:
Durable Medical Equipment Order Form
DELIVERY DAY
Day
As of Date
Addtional Delivery/Pick Up Data: 
Time:
CONFIDENTIAL Privleged Patient Medical Records.  Information is protected under federal and/or state law and is intended only for the use of the individual or entity named above.  If the reader of this information is not the intended recipient, you are hereby notified that any dissemination, distribution or copying of this information is strictly prohibited; immediately destroy any copy in your possession.
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Beds and Accessories:
Bathroom Items:
Reason
To Print  Order....Right Click on Screen....Select Print Function
Be Sure to Print Order Prior to Submitting Order
Wheelchairs:
Additional Order Comments:
Patient Lifts:
Oxygen:
LPM:
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  Quantity
Other Items:
Bariatric Products > 300 lbs:
Premium Items Need Authorization


For Sale Items:
Walkers and Canes:
-------PICK UP DATA-------
Feet        Inches
(Whole Pounds)
Patient Middle Name:
Patient Last Name:
**Authorized By:
Semi Electric Bed
HiLo Electric Bed
Mattress - Concave
Mattress - Foam
APP- Alternating Pressure Pad
OTBT - Over The Bed Table
Floor Mat
Rails
Rail Pads - Bolsters
Bed Cane - Positioning Bar
Gel Overlay
Other
Standard Wheelchair
Wide Wheelchair
Light Wgt Wheelchair
Transport (Comp) Wheelchair
Hemi Wheelchair
Geri Chair with Tray
Reclining Hi-Back W/C
ELR Elevated Leg Rests
Footrests
Other
Cable Brake Walker
FWW Front Wheel Walker
Cane
Other
BSC Bed Side Commode
Shower Chair
Sliding Transfer Bench
Other
Hydraulic Patient Lift
Trapeze Floor
Other
Concentrator
Conserving Device
CPAP (Mask Not Incl)
Regulator
Suction Machine
Small Volume Nebulizer
Tanks
Other
Alarms
Enteral Feeding Pump
IV Pole
Other
Bariatric Bed Side Commode
Bariatric Shower Chair
Other
Bariatric Beds
Bariatric Low Air Loss Mattress
Bariatric Wheelchair
BiPAP (Mask Not Incl)
Electric Patient Lift
Enteral Formula
LAL Low Air Loss Mattress
Electric Lift Chair
Liquid Oxygen
Power Wheelchair
Power Scooter
Other
Bed Wedges
BiPAP Mask
CPAP Mask
Feeding Bags for Enteral Pump
Protectors
Skin Sleeves
T.E.D.
Compression Hose
Washable CHUX
Other