Equipment Order Form I.M.S. Clifton, NJ (973) 478-9219

Equipment Order Form

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Patient Contact Information First Name * Last Name * Address City State/Province Zip Phone Referred By Requested Delivery Date Please Choose One Contact patient for insurance, payment and physician information. I will fill out the insurance billing info to the right.	Insurance Billing Information Birth Date Height Weight SSN Diagnosis Physicians Name Physicians Phone Private Insurance Carrier Patient Identification Number Medicare Number Secondary Insurance Carrier Secondary Insurance
Wheelchairs Standard Wheelchair (16", 18" or 20" only) Light Weight Wheelchair (16", 18" or 20" only) Hemi Height Wheelchair (16", 18" or 20" only) Heavy Duty Wheelchair (20", 22" or 24" only) Choose Size: Choose Arm Type: Choose Front Rigging: Wheelchair Accessories Anti-Tipper Brake Extension Seat Belt Arm Trough Choose Arm Trough Side: Reclining Back Oxygen Tank Holder Transfer Board Transport Chair Choose Transport Chair Size: Ambulatory Choose Adult Walker Type: Choose Junior Walker Type: Heavy Duty Walker Canes Straight Cane Offset Cane Choose Quad Cane Type: Side Pyramid Cane (aka Hemi Walker) (Prescription is required prior to delivery)	Hospital Bed and Accessories Choose Bed Type: Choose Rail Type: Alt Pressure Pad and Pump Low Air Loss / Alt Pressure Mattress Trapeze Home Style Bed Rails Over Bed Table Bedside Transfer Handle Bath Safety Products Shower Bench w/o Back Shower Bench w/ Back Bathtub Transfer Bench Choose Transfer Bench Type: Raised Toilet Seat Raised Toilet Seat With Arms All-in-one Commode Drop Arm Commode Extra Wide Commode Site Survey Stair Lift Site Survey Modular Ramp Site Survey Walker Accessories Three Inch Wheels Five Inch Wheels Choose Five Inch Wheel Type: Tall Extensions Tall Extension w/ Three Inch Wheels Choose Platform Attachment Type: Wheelchair Cushions Two Inch Foam Cushion Two Inch Foam Cushion Gel Foam Cushion Rollator Go-Lite Rollator
Special Instruction Please list:	Provide Me the Following Info Lift Chairs Scooter Power Chairs Stair Lifts Ramps Vehicle Lifts

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