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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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Tennessee
Texas
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West Virginia
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Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
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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:
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