Respiratory Order Form

Medical Center Respiratory
Your Respiratory and Medical Equipment Specialist

"Everything for Patient Care at Home"

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Medical Center Respiratory Order Form

Medical Center Respiratory
908 S.16th Street
Wilmington, NC 28401

Customer Service
Phone: 910-762-7007
Toll Free: 800-300-7770
Fax: 910-762-7062

Discharge Facility
*Highlighted Fields Required*
Ordering Physician: Discharging Facility:
Case Manager/ Discharge Planner: E-mail:
Phone : Pager : Discharge Date: , 20
Patient Information
Date: , 20	Date of Birth: ,
Last Name:	First Name: MI :
Address :	Social Security #: Sex: M F
City :	Diagnosis:
State : Zip Code:	Patient Phone #:
Emergency Contact :	Emergency Contact Phone #:
Insurance Information
Insured Name: Last First: MI: Primary Insurance Carrier: If Other Please Specify: Policy/Group #: Member #: Phone:
Secondary Insurance: Policy/Group #: Member #:
Equipment
Respiratory Services	Durable Medical Equipment
Home Oxygen w/portable	Power Wheelchair	Wheelchair Accessories Brake Extension Seat Belt Anti-Tippers Cushion
LPM	Lightweight Wheelchair
O2 Saturation % or PO2 mmHg	Standard Wheelchair
At Rest At Exercise At Sleep	Companion / Transport Chair
CPAP Settings: cm H2O
BiPAP Settings: / cm H2O	Semi-Electric- Hospital Bed
Oxygen Included:	Accessories: Trapeze Bar Over Bed Table
Yes No	Lift Chair / Recliner
LPM	Light Weight Folding Walker
Overnight Pulse Oximetry	Walker w/wheels
Sleep Apnea Link	Walker w/seat & brakes
	Hoyer / Patient Lift
	Bedside Commode
Nebulizer Medications: Dosage/Frequency:
Other:
Delivery Instructions
Location: Residence: Facility: Other:
Address: Room #: Bed #:
City: State: Contact Phone:
*Confirmation Preference: Phone Email
Please include any special instructions in the box below.

We bill Medicare, Medicaid, and most private insurances.*
Please Note: All orders received after 5pm will be processed on the following business day.