Medical Equipment and Supplies Reorder Form

Please complete the form below to reorder your medical equipment and supplies. Note that required fields are indicated below.

This form is for existing claimants only.

If you are a new claimant, please call us at 1-888-586-4650.

Medical Equipment and Supplies Reorder Form

Patient Information

Patient Name(Required)

First Last

Patient Phone(Required)

Comments(Required)

Please let us know what's on your mind. Have a question for us? Ask away.

TENS ITEMS

Electrodes

EP84750 (Comfort-Stim - 1.5" x 13")

How Many?

RD01 (Comfort Stim - 1.25")

How Many?

4848 (Comfort-Stim - 2" x 2")

How Many?

EC89375 (Carbon Electrode - 2 "x 2")

How Many?

RG02 (Super-Stim - 2" x 3.5")

How Many?

BT03 (Soft-Stim Butterfly - 4" x 6")

How Many?

EC89041 Single Stim - (Disposable Electrode - 2.25" x 2.5")

How Many?

48R (Super-Stim - 2")

How Many?

Batteries

Rechargeable 9 Volts

How Many?

Rechargeable AA

How Many?

Rechargeable AAA

How Many?

Battery Chargers

9 Volts

How Many?

AAA

How Many?

Lead Wire

D836B (TENS Leadwire - 42")

How Many?

Other TENS Items

Pretac

How Many?

Alcohol Wipes

How Many?

Clean Cote

How Many?

Remover

How Many?

Ostomy

Antibacterial Cleaners

How Many?

Bedside Bags

How Many?

Catheters

How Many?

Gloves

How Many?

Leg Bags

How Many?

Ostozyme Spray

How Many?

Skin Prep

How Many?

Tape

How Many?

Underpants

How Many?

Lotions

Aloe Vera Lotion 4 oz.

How Many?

Vitamin E Lotion 12 oz.

How Many?

Sween Cream 12 oz.

How Many?

Aloe Vera Gel 4 oz.

How Many?

Cocoa Butter Cream 9 oz.

How Many?

Topical Pain Relievers

Biofreeze Tube 4 oz.

How Many?

Biofreeze Roll-on 3 oz.

How Many?

Statogesic Pads

How Many?

Hearing Aid Batteries

Size 5

How Many?

Size 10

How Many?

Size 13

How Many?

Size 312

How Many?

Size 675

How Many?

Cane Items

Crunch Tips

How Many?

Other Items

ThermaCare Heat Wraps

How Many?

Paraffin Refills

How Many?

Other

How Many?

Notes