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Fremont: (231) 924-4040 | Muskegon: (231) 737-7070 | Grand Rapids: (616) 888-2056

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Equipment Order Form

Phone: 616-888-2056
Attachments needed
*facesheet
clinical notes

Office/Facility Name

File

Max. file size: 100 MB.

**Ordered by

Print Name

Phone#

Patient Name

DOB

MM slash DD slash YYYY

Length of Need (1 to 99)

Please enter a number from 1 to 99.

Diagnosis/ICD10

Height

Weight

Discharge Date

MM slash DD slash YYYY

Physician’s full name

Comment: (Any specific discharge plans)

Walkers, Canes & Crutches

Standard Walker

Standard Cane

Quad Cane

Knee Walker ($39 a month)

Crutches

Rollite Walker w/ seat (swivel wheels) :

Rollite Walker w/ seat (fixed wheels) :

Standard Walker w/ wheels :

Bariatric Knee Walker ( $75 a month)

Rollator Walker w/ seat & brakes

6"

8"

Rollator Walker w/ seat & brakes

Standard Walker

Youth

Adult

Tall

Standard Walker

No Wheels

5” Fixed

5” Swivel

3” Swivel

Standard Walker

Quad Cane

Large Base

Small Base

Quad Cane

Crutches

Youth

Adult

Tall

Crutches

Rollite Walker w/ seat (swivel wheels)

swivel wheels 6 8

6"

8"

Rollite Walker w/ seat (fixed wheels)

fixed wheels 6 8

6"

8"

Standard Walker w/ wheels

wheels 3 5

3"

5"

Wheelchair & Wheelchair Accessories

Wheelchair

Size

16X16 16X18 18X16 18X18 20X16 20X18 22X18 24X18 26X20 28X20 30X20

Wheelchair

Light Weight

Reclining

Transport

Power Mobility Device

Gel Cushion

Foam Cushion

Roho Cushion

Wheelchair Accessories

Foot Rest

Anti-Tippers

Brake Extensions

Wheelchair Back Cushion

O2 Holder for W/C

Adustable Height Arms

Elevating Foot Rest

Arm Trough Right

Arm Trough Left

Elevating Foot Rest

L

R

Elevating Foot Rest

Half Lap Tray

R

L

Hemi-kit

Hospital Beds (full electric)

Hospital Beds - Rails

Half Rails

Full Rails

Hospital Bed (Full Electric)

App Pad & Pump

Group 1 Mattress (Memory Foam)

Group 2 - Air

Standard w/ APP Pump

Standard Innerspring

Respiratory Equipment

Oxygen at*

Oxygen at

(Please provide documentation)

At Rest

LPM

HPD (Hours Per Day)

Saturation Rate (88 or under)

With Exercise

Resting room sat rate

Room air sat rate with ambulation (88 or below)

Sat rate with prescribed oxygen during amb

Respiratory Equipment cb

Portable finger oximeter ($39.99 pvt pay)

Nebulizer

Aerosol Mask

Aerochamber

Portable suction unit

Heavy duty compressor (mist to trach)

Trach supplies:

Trach supplies

Commode

Standard Commode (up to 300 lbs.)

Bariatric Commode (over 300lbs.)

Drop Arm Commode

Bariatric Drop Arm Commode

Transfer Equipment

Hoyer Lift

Sit to Stand

Transfer Board

Transfer Board

24"

30"

Transfer Board

Sling Options

SLING OPTIONS

U sling w/ head support

Full Body Sling w/ commode opening

Other Durable Medical Equipment

Glucometer Testing

Other Durable Medical Equipment

Enteral Pump Formula:

Enteral Pump Formula

Rate

Hours Per Day

Other Section

Other section

Phone

This field is for validation purposes and should be left unchanged.

(231) 737-7070

CSR@air-caire.com

Fremont Location:
16 East Sheridan St.
Fremont, MI 49412

Muskegon Location:
2440 Glade St.
Muskegon, MI 49444

Grand Rapids Location:
3554 Alpine Ave
Grand Rapids, MI 49544

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