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ELECTRONIC INTAKE FORM
PERSON PLACING THE ORDER
*
CONTACT NUMBER:
*
AGENCY
*
PATIENT TYPE (SELECT ONE)
*
NEW
EXISTING
REVOCATION
DISCHARGE
READMIT
IF REVOCATION/DISCHARGE/READMIT PLEASE SPECIFY DATE:
+
PATIENT INFORMATION
PATIENT NAME (LAST, FIRST)
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PATIENT STREET ADDRESS (HOUSE NUMBER, STREET NAME, APT NUMBER ETC.)
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CITY
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ZIP CODE
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PRIMARY PHONE CONTACT (NAME & NUMBER)
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SECONDARY PHONE CONTACT (NAME & NUMBER)
ORDER PLACEMENT
WHAT TYPE OF SERVICE NEEDS TO BE PERFORMED?
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DELIVERY
PICK UP
SERVICE
OTHER
OTHER
WHEN WOULD YOU LIKE THE ORDER DISPATCHED?
*
NEXT DAY
TODAY
ASAP
EQUIPMENT
HOSPITAL BEDS
FULLY ELECTRIC HOSPITAL BED (STANDARD)
LOW FULLY ELECTRIC HOSPITAL BED
HEAVY DUTY HOSPITAL BED
MATTRESS
GEO MATTRESS (STANDARD ON EVERY HB)
INNER-SPRING MATTRESS
ALTERNATING PRESSURE PAD (OVERLAY ON INNER)
LOW AIR LOSS (STAGE 2)
APM2 (STAGE 2)
HEAVY DUTY GEO MATTRESS
HEAVY DUTY APM2
GEL MATTRESS OVERLAY
OTHER:
OTHER:
HOSPITAL BED ACCESSORIES
HALF RAILS
LOW HOSPITAL BED FLOOR PAD
BED RAIL PADS (PAIR)
TRAPEZE BAR
HEAVY DUTY TRAPEZE BAR
SMALL BED WEDGE
MEDIUM BED WEDGE
LARGE BED WEDGE
OXYGEN
5 LITER CONCENTRATOR
10 LITER CONCENTRATOR
HOMEFILL SYSTEM (WITH 2 BOTTLES)
E TANK SYSTEM (INCLUDES 3 E TANKS, REGULATOR, WHEELED CART)
125 LITER EMERGENCY BACKUP TANK
M6 SETUP (INCLUDES 4 M6 TANKS, CARRYING BAG, CONSERVOR)
REGULATOR
CONSERVOR
CPAP (1 SETTING)
BIPAP (2 SETTINGS)
BIPAP ST (2 SETTINGS, PLUS BACKUP RATE)
E TANK REFILLS
M6 TANK REFILLS
IF TANK REFILLS SPECIFY QUANTITY:
IF TANK REFILLS SPECIFY QUANTITY:
LIQUID OXYGEN
LIQUID OXYGEN BASE
LIQUID OXYGEN SMALL PORTABLE
LIQUID OXYGEN LARGE PORTABLE
LIQUID OXYGEN BASE REFILL
OTHER:
OTHER:
ADDITONAL EQUIPMENT
NEBULIZER
HIGH VOLUME NEBULIZER (TRACH PATIENTS)
SUCTION MACHINE
GASTRIC SUCTION
NEB MASK WITH TUBING
NEB SET WITH TUBING
WHEELCHAIRS & ACCESSORIES
16" WHEELCHAIR
18" WHEELCHAIR
18" LIGHT WEIGHT WHEELCHAIR
20" WHEELCHAIR
22" WHEELCHAIR
24" WHEELCHAIR
TRANSPORT WHEELCHAIR (18")
GERI-CHAIR
HEAVY DUTY GERI-CHAIR
GEL FOAM WHEELCHAIR CUSHION
POMMEL WHEELCHAIR CUSHION
OTHER:
OTHER:
AMBULATORY NEEDS
OVER THE BED TABLE (OBT)
SHOWER CHAIR
HEAVY DUTY SHOWER CHAIR
TRANSFER BENCH
HEAVY DUTY TRANSFER BENCH
BED SIDE COMMODE
DROP ARM BED SIDE COMMODE
HEAVY DUTY BED SIDE COMMODE
CANE
QUAD CANE (MEDIUM BASE)
WALKER WITH WHEELS
WALKER NO WHEELS
ROLLATOR
HEAVY DUTY ROLLATOR
OTHER:
OTHER:
FEED PUMPS
COMPACT FEED PUMP
PATROL FEED PUMP
QUANTUM FEED PUMP
KANGAROO FEED PUMP
KANGAROO E FEED PUMP
IV POLE
BAGS:
BAGS:
OXYGEN FLOW (IF ORDERED)
1 LPM
2 LPM
3 LPM
4 LPM
5 LPM
6 LPM
7 LPM
8 LPM
9 LPM
10 LPM
11 LPM
12 LPM
13 LPM
14 LPM
15 LPM
16 LPM
17 LPM
18 LPM
19 LPM
20 LPM
ADDITONAL COMMENTS CONCERNING SERVICE: (IE. O2 TUBING NEEDS, DIRECTIONS TO HOME, SPECIAL TIMING NEEDS)
TO RECEIVE A CONFIRMATION EMAIL, PLEASE ENTER YOUR ADDRESS BELOW:
TO SEND A ANOTHER CONFIRMATION EMAIL, PLEASE ENTER THE ADDRESS BELOW:
TO SEND ANOTHER CONFIRMATION EMAIL, PLEASE ENTER THE ADDRESS BELOW:
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