* = Required Information

Primary Physician: *
UPIN#
*Items that are patient pay or need to be pre-qualified before delivery
CLINICAL ASSESMENTS
Pulse
Overnight
BATHROOM
Bedside Commode
Drop Arm
Heavy Duty
Elevated Toilet Seat* $26
W/Arm* $78
Shower Chair* $ 45
Heavy Duty* $ 115
Transfer Bench* $ 85
Heavy Duty* $ 150
RESPIRATORY
CPAP/BIPAP
EPAP/IPAP
Mask size
Nasal
Full
Oxygen
(LPM , o2SAT)
Suction Machine
Trach/Cath
Size
Oral
Trach Care Kits
Nebulizer
AMBULATORY
Cane
Quad Cane
Crutches
Hemi Walker (side)
Rolling Walker
  • Junior
  • Heavy Duty
  • No Wheels
  • Basket/Pouch* $25/$30
  • Seat Attachment
Platforms Attachments
Rollator* $175
  • Junior $101
  • Heavy Duty $ 150
ENTERAL FOOD
Formula
Flow Rate
Cans or Calories/Day
Bolus
BEDDING
Hospital bed
Full Rails
Half Rails
Heavy Duty
Lo Beds
Gel Overlay Mattress*
Alt. Pressure/ Air loss
Trapeze Bar
  • Free Standing
MOBILTY
Wheelchair Size
  • Standard
  • Lt. Weight
  • Bariatric
  • Hemi Height
  • ELR's:
Standard Cushion
Power Wheelchair
Gel/ Roho
Scooter
MISC.
  • CPM- Setting  
  • Right
     
  • Left
     
  • Patient Lift
     
  • Std. Sling
     
  • Diabetic Supplies
     
  • Strips/Day
     
  • ADL Kit*
     
  • Economy $ 40
  • Deluxe $45
  • Auto Blood Press.
     
  • Monitor* $35+
     
  • Resorator/ Peddler* $ 45
     
  • Other