ORDER FORM

 NEW UTRECHT AVE., BROOKLYN, NY 

TEL:718.437.0066 · FAX:718.437.0088 ACCREDITED BY THE

TOLL FREE:1.866.437.0066 JOINT COMMISSION ON ACCREDITATION

OF HEALTHCARE ORGANIZATIONS

Order Date:_____________ Delivery Date:_____________

PRESCRIBER’S INFORMATION:
PATIENT INFORMATION: Facility Name__________________________________________
Name____________________________________________ Doctor’s Name________________________________________
Address________________________ Apt#____________ NPI #_____________________ Lic. #______________________
City_______________________ Zip_______ D.O.B_______ Contact Person________________________________________
Tel._____________________________ Ht._____ Wt._____ Phone #______________________________________________
Medicare/other#__________________________________ Fax #_____________________ Email:_____________________
Medicaid #_______________________________________ Address______________________________________________
Diagnosis________________________________________ Prescriber’s Signature__________________________________

INCONTINENT SUPPLIES
 Diapers:  Sm  Med  Lg  XL
 Diapers Pullups:  Sm  Med  Lg  XL
 Chux
 Cloth Chux
 Standard wheelchair for  Motorized wheelchair  Semi-Electric Bed with  Over-bed Table  Incontinent liners:  4 x 10  7 x 17
patient who CAN self  Motorized Scooter mattress  Gel Overlay  Incontinent pants:  Med  Lg
propel.  Bed Only  Air Mattress
 Light-weight wheelchair  Gloves:  Med  Lg
 Bariatric/heavy-duty
for patient who CAN NOT equipment  Incontinent package (includes all of above)
propel in a standard
wheelchair.

NUTRITIONALS
AUTH. #
 Ensure  Pediasure
 Ensure Plus  Glucerna

 Raised toilet seat  Commode  Shower chair  Patient lift COMMENTS OR OTHER SUPPLIES
 Toilet Frame  Transfer bench

 Walker with wheels  Rollator  Large quad cane  Tub rail

 Walker with Glides  Small Quad cane  Grab bar
 Standard cane

 Oxygen  Nebulizer  CPAP  BiPAP  Suction Machine

 Heated humidification  Suction Supplies

PLEASE EMAIL YOUR REQUEST TO: Orders@primemedsupply.com