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.....Ambulatory Aids
.....Respiratory
.....Bath Aids
.....Beds
.....Wheelchairs
.....Therapeutic Support Surfaces
.....Lifts & Slings
.....Enteral Feeding
.....Suction Pumps


.....
Phone: ...919.876.4336
.....Fax: .......919.876.4485
.....Address: 3430 Tarheel Drive,
...................Suite 104
...................Raleigh, NC 27609

 

  PATIENT INFORMATION AND EQUIPMENT ORDER FORM

Referral Information
Date: Referral Source:
Your Name:
Phone:
Email:

Patient Information
Name:
Address:
City: State: ZIP:
Phone: Social Security Number:
Gender: Date of Birth:
Height: Weight:
Diagnosis:
2nd Diagnosis:
3rd Diagnosis:

Caregiver Information
Name:
Address:
City: State: ZIP:
Relationship:
Home Phone: Work Phone: Cell/Mobile Phone:

Insurance Information
PRIMARY: Policy #: Group No. / Company:
Address:
City: State: ZIP:
Phone:

SECONDARY: Policy #: Group No. / Company:
Address:
City: State: ZIP:
Phone:

Physician Information
Name:
Address:
City: State: ZIP:
Phone: UPIN:


Equipment Order
Oxygen
  O2 Concentrator Portable Conserving Device
  LPM:
  Blood Gas/PO2 Result:
  Pulse Ox Sat. % Result:
  Date of ABG: Place:
 
CPAP BIPAP
  Type of Mask: Apnea Events/hr: Setting (cm/H2O):
  Cool Humidification Heated Humidification
 
Enteral Feeding
  Type of food needed: cc/hr:
 
Nebulizer
 
Bedside Commode 3 in 1 Drop-Arm
 
Wheelchair
  Standard Lightweight ELR
  With Low-Pressure Cushion Power Reclining
 
Electric Hospital Bed
  Trapeze Bar Alternating Pressure Mattress
  Alternating Pressure Pad Over Bed Table
 
Folding Walker With Wheels
 
Canes Single Point Quad
 
Crutches Height:
 
Patient Lift
 
Suction Machine
 

Comments:


PLEASE READ BEFORE SUBMITTING: TO RETAIN A COPY OF YOUR EQUIPMENT REQUEST FOR YOUR RECORDS, PLEASE PRINT THIS PAGE NOW. ONCE THIS FORM IS SUBMITTED YOU WILL BE UNABLE TO ACCESS THIS DOCUMENT VIA YOUR COMPUTER. PLEASE CALL AHHC AT 919-876-4336 IF YOU HAVE QUESTIONS.