FamilyHomeMedical.com
 

866.624.0127

 

 

'You're Going To Love The Way Our Family 

Takes Care Of Your Family, I Guarantee It.'

Contact Us

 

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Main Menu

Home

Bathroom Equipment

CPAP/BIPAP

Lift Chairs

Mastectomy

Power Wheelchairs

Scooters

Walkers

Wheelchairs 
About Us
 
 

Refer Now - Patient / Client

Accepted primary insurances:    Medicare, Blue Cross Provider, Tricare & Evolutions

Patient's / Customer's: Please fill out the below

Name  

Phone 

Street  

City   

State   

Zip    

 Email 

DOB 
State of Residence   Social Security #

Weight         Height   

Primary Insurance  Carrier

Policy
Secondary Insurance  Carrier Policy
Primary Physician  Physician's  Phone
Ordering Physician Physician's Phone
Next of Kin Next of Kin Phone

Please select the equipment needed.

Walker w/o wheels         View

 Wheelchair- STD           View Bedside commode            View
Walker - front whld        View Wheelchair - LTW         View Drop Arm commode        View
Walker - three whld        View Wheelchair - Comp        View Bariatric commode           View
Walker - four whld         View Elevating leg rest             View Bath bench                       View
Cane - straight                View Cushion with back          View Bath transfer bench           View
Cane - quad                   View  Cushion- seat only          View Raised toilet seat              View
Crutches                         View Motorized scooter          View Motorized wheelchair       View
  Hospital bed                   View Alternating mattress        View Trapeze                            View
  Vacuum Pump   Silicone Form   Mastectomy Bra
  Oxygen Concentrator   Oxygen Portable Conserving Device
  CPAP/BIPAP   CPAP Supplies   Lift Chair
  Electric Scooter   Electric Wheelchair  

Other equipment needed

Special notes

Do you have a prescription for the requested equipment/Product   Yes      No

Our store hours are Monday - Friday 9am to 7pm

Any documents can be faxed to 866.628.7183

Thank you for the order. A staff member will contact you shortly.

 
 
 

Let our family serve yours.


 Thank you. Your referral is greatly appreciated.

Should you wish to contact an owner directly email: burtross@usa.net

 

 

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