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Hospice Supplies Order Form
Desert Tech Pros
2020-12-05T19:38:49-07:00
Requested By
*
Company's Name
*
Phone Number
*
Email Address
*
Patient's Information:
Patient's Name
*
First
Last
Patient's Contact
*
Contact's Phone Number
*
Delivery Address
*
Street Address
City
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American Samoa
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Delaware
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Maryland
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Michigan
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New Hampshire
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New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
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Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
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Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
When would you like to have your order delivered?
Date
*
MM slash DD slash YYYY
Time
*
:
Hours
Minutes
AM
PM
AM/PM
Please select the supplies that you would like to have delivered:
For multiple items of the same type, please indicate the quantity needed in the fields at the bottom.
Beds and Accessories:
App - Alternating Pressure Pad
Bed - Extra Long Pkg
Bed - HiLo Electric
Bed - Low
Bed - Semi Electric
Floor Mat - Beveled
Mattress - Concave
Mattress - Foam
OTBT - Over the Bed Table
Rail Pads
Rails - Full
Rails - Half
Wheelchairs:
ELR - Elevated Leg Rests
Geri Chair
W/C - Hemi
W/C - Lite Weight
W/C - Reclining High-Back
W/C - Standard: 16", 18". 20"
W/C - Transport / Companion Chair
Walkers/Canes:
Cane - Mono Tip Straight Cane
Cane - Quad Cane
Walker - Cable Brake or Push Walker
Walker - FWW - Front Wheel Walker
Bathroom:
BSC - Bed Side Commode
Rolling Shower Chair
Shower Chair
Shower Chair with Back
Sliding Transfer Bench
Oxygen:
Concentrator, 5L
Concentrator, 10L
Conserving Devices
CPAP (without the mask)
Regulators
Suction Machine
SVN - Small Volume Nebulizer
Oxygen Tanks: E Size
Oxygen Tanks: C Size
Oxygen Tanks: M6 Size
Patient Lifts:
Hydraulic Hoyer
Trapeze - Floor
Bariatric Products:
Commode
Shower Chair
Other Items:
Alarms: Bed, Chair or Personal
Enteral Feeding Pump
IV Pole
Wheelchair Cushions
Premium Items:
Bariatric Trapeze
Bariatric Wheelchair
Lift Chair - 3 Position
Low Air Loss Mattress
BiPap
Patient Lift - Electric
Bariatric Bed
Bariatric Low Air Loss System
Liquid Oxygen - 1-2 lpm
Power Wheelchair or Scooter
Patient Lift - Stand Up
Concentrators - Portable
BiPAP St - (Mask not Included) $20.00 per day
Moves - Additional Location Equipment Setup $75.00 per move
Patient Weighing - Wheelchair & Hoyer
Hi FLow Liquid O2 - Price Determined on Usage
Bariatric Products - Prearranged pricing by item
Enter Feedings - Prearranged pricing by item
One Time Sale Items:
CPAP or BIPAP Masks
Heel Protectors
T.E.D. or Compression Hose
Other Items Not Listed:
Please also include notes about multiple quantity items here.
Notes or Special Instructions:
Additional Documentation Upload
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Accepted file types: pdf, jpg, jpeg, doc, docx, xlsx, Max. file size: 256 MB.
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