Equipment Order Form Phone: 616-888-2056 Attachments needed *facesheet clinical notes Office/Facility Name FileFileMax. file size: 100 MB.**Ordered by Print NamePhone#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 & CrutchesWalkers, 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 & brakesStandard Walker Youth Adult Tall Standard WalkerStandard Walker No Wheels 5” Fixed 5” Swivel 3” Swivel Standard WalkerQuad Cane Large Base Small Base Quad CaneCrutches Youth Adult Tall CrutchesRollite 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 AccessoriesWheelchair Wheelchair Size16X16 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 AccessoriesWheelchair 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 RestHalf Lap Tray Half Lap Tray 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 EquipmentOxygen at* Oxygen at (Please provide documentation)At RestLPM HPD (Hours Per Day) Saturation Rate (88 or under) With ExerciseResting 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 CommodeCommode Standard Commode (up to 300 lbs.) Bariatric Commode (over 300lbs.) Drop Arm Commode Bariatric Drop Arm Commode Transfer EquipmentTransfer Equipment Hoyer Lift Sit to Stand Transfer Board Transfer Board 24" 30" Transfer BoardSling OptionsSLING OPTIONS U sling w/ head support Full Body Sling w/ commode opening Other Durable Medical EquipmentOther Durable Medical Equipment Glucometer Testing Glucometer Testing Other Durable Medical Equipment Enteral Pump Formula: Enteral Pump Formula Rate Hours Per Day Other Section Other Section Other section PhoneThis field is for validation purposes and should be left unchanged.