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Home > Referrals
 

Referrals


Please enter all relevant information to help us serve you. We are retail store therefore we do not bill insurances.        
Patient Name

  SSN#
Phone Number
  Address
Date of Birth
  City
State
  Zip Code
Emergency Contact Person
  Emergency Contact Phone

Height           
 


Weight
         


            
 
             

  
 
                 
Diagnosis (ICD-9)
 
       
Length of Need
 

     
Months (1-99) *99 = lifetime
       
   
 

Ambulatory

   
Wheel Chair

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    Walker            Wheels
      
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Cane

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Transfer Bench

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Quad Cane

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Raised Toilet Seat

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3-in-1 Commode

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Hand Held Shower

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Bed Options

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Grab Bar

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Hospital Bed

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Trapeze Bar

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Patient Lift

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Respiratory

 
Nebulizer
 

       
Medication  
Times Per Day:  
     
 
     


 

       
 
       
 
Other Equipment Needed
Notes
 
 
 
Referred By
  Facility Name
     
Ordering Physician's Name
  Referring Physician's Phone Number
     
Your Name
  Your Phone Number
     

Discharge Date

  Requested Delivery Date & Time
     
Please note, Rx may be required prior to dispensing. We will follow up with you as soon as possible. Thank you for your business!  

     
For questions or comments please contact Clark's Rx Home Medical at: 937-433-6661
Hours: Mon-Fri 10:00 a.m. - 6:00 p.m.
Sat 10:00 a.m. - 2:00 p.m. Closed Sun