September 6, 2010

• DEALER LOCATOR
• TESTIMONIALS
• FAQs
• HOMELINK U
• EQUIPMENT & SERVICES
• REQUEST PRODUCT
INFORMATION
• SATISFACTION SURVEY
• ORDER PICK UP
• ONLINE ORDERING
• PLACE NEW ONLINE ORDER
• PLACE RE-ORDER
• QUICK REFERRAL

Dedicated service
direct numbers

Worker's Compensation &
Catastrophic Care
800-571-2943

Group Health
800-482-1993

Transportation
866-496-3580

Pick Up Request Form

Today's Date: Monday, September 6, 2010

Request From: Company:
Phone:

Patient Name:
Insured Name:		Insured SSN:
Patient Address:
City, St, Zip		,

Item to Pick Up	Date to Pick Up

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