Medical Equipment Patient Information

Medical Equipment Patient Information

The medical equipment department will reach out to you within 72 business hours (M-F) after the completion of this form to follow-up. If you have any questions please call us at 804-288-8361 ext 134.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address ( Must be in the state of Virginia)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Please Select Primary Insurance*
Please List Insurance ID and Group Number

ID NumberGroup Number
Please upload a copy of the front and back of your insurance card.*

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What product(s) are looking for?*

Knee ScooterRollatorWalkerCrutchesCaneBraces for the wrist, ankle, back, knee, neck, and carpal tunnelShower ChairsElevated Toilet SeatsBlood Pressure MonitorsMaternity SupportOther
Do you have a prescription for the product(s) selected above?*

YesNo
Please list your doctor's name.

First NameLast Name
Please list your doctor's phone number.
Please enter a valid phone number.
Please list the diagnosis code or reason listed on the prescription of why this is being prescribed.
ICD-10 Code ex: R60.0 (edema)
Please upload a picture of the prescription.

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Disclaimer: Not all products are covered by inusrance. A trained staff member will review your information and call you to let you know if the product needed is covered.
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