Hospice Order Form

Hospice DME Order Form
Location *

Kauai Maui
Hospice Representative *
Hospice Representative Cell Phone Number
Hospice Representative Email Address (For Confirmation - Optional)
Patient Last Name *
Patient First Name *
Patient Full Name *

First Name Last Name
Date of Birth
Phone Number
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Person of Contact
Relationship

Brother Caregiver Daughter Friend Husband Sister Son Wife
Additional Phone Number
Patient Height (inches)
Patient Weight (lbs)
Delivery Urgency *

Next Business Day URGENT - Facility Discharge
Time Request - 9am-4pm (We will do our best to accommodate or get as close to the requested time as possible.)
Hospice Package

Electric bed with mattress and half rails, Oxygen Concentrator - 5LPM, Over Bed Table, APP with mattress
Package Add-Ons

Eggcrate, 4" Low Air Loss Mattress Portable Oxygen Concentrator - 5LPM Tilt-N-Space Manual Wheelchair
Mobility Items (Ala Carte)

Walker, Front Wheeled Walker, Rollator Wheelchair, Transport Wheelchair, Standard Wheelchair, Heavy Duty Wheelchair, Extra Heavy Duty Wheelchair, Reclining Wheelchair, Elevating Legrests
Beds and Accessories (Ala Carte)

Semi Electric Hospital Bed with 1/2 Rails and Mattress Full Electric Hospital Bed with 1/2 Rails and Mattress Bed Rails, Full Trapeze Bar (Attached to Hospital Bed) Eggcrate, 4 inch APP with Mattress Low Air Loss Mattress Over Bed Table Patient Lift with Sling
Commode and Bath Items (Ala Carte)

Commode, Bedside Commode, Bariatric Shower Chair with Back Transfer Bench Rolling Shower Chair
Respiratory Items (Ala Carte)

Oxygen Concentrator, 5 LPM Oxygen Concentrator, 10 LPM Portable Oxygen Concentrator - 5 LPM Oxymask Oxygen Mask (For liter flows 1-15 LPM) Standard Oxygen Mask (For liter flows 6+ LPM - no charge option) Suction Unit Suction Unit Supplies (2 canisters, 2 tubing, 2 yankauers) Nebulizer Unit Nebulizer Kit Nebulizer Mask
If oxygen has been ordered, please indicate the liter flow needed:

2 LPM to 4 LPM
Comments - Please notate any order specifics here.
Should be Empty:

Hospice DME Order Form