Korman Healthcare

Korman Healthcare Respiratory-DME Order Form


For questions call: 480-365-0222 OPTION #3

Include Physicians orders as applicable
Missing/incomplete information may delay processing

Patient Name:   

Address:  

 

Sex:

 
Height Weight

 
Hospice Name:  


Caller: Phone:  


Person completing this form:  

 

Delivery To:

 

Physician:

RESPIRATORY THERAPIES

 

Home Oxygen Concentrator:

LPM (if selected) :  

 

Pressure Setting (required) 

Mask size/type: ~or~

 


DURABLE MEDICAL EQUIPMENT

Wheelchairs:

Type:

Width:

Accessories:

Geri Chair:

 

Hoyer Lift w/Sling:

 

Walker: 

 

Hospital Bed: (<350lbs, 80”)

Commode:

 

Shower Chair:

Transfer Bench:

Other:


Physician/Prescriber Signature X: 

 

Leave this empty:

Signature arrow sign here


Signature Certificate
Document name: Korman Healthcare Respiratory-DME Order Form
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August 26, 2022 5:52 pm EDTKorman Healthcare Respiratory-DME Order Form Uploaded by Mark McKee - mmckee@box2394.temp.domains IP 72.23.75.40
September 8, 2022 6:10 pm EDTWebsite to DocuTrack - docutrack@box2394.temp.domains added by Mark McKee - mmckee@box2394.temp.domains as a CC'd Recipient Ip: 72.23.75.40
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