Hospice Order Form

Hospice DME Order Form
Location*

KauaiMauiLanai
Type of Care*

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

First NameLast Name
Date of Birth

MonthDayYear
Date
Date of Birth
Phone Number

Area CodePhone Number
Phone Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Contact Person*
Patient Height (inches)
Patient Weight (lbs)
Delivery Urgency*

Next Business DayURGENT - Facility DischargeNone - Pick up at Gammie HomeCare OfficeOther
Time of Day Request (We will do our best to accomodate or get as close to the requested time as possible).

AM (10a-1p)PM (2p-5p)Anytime
Additional Comments for time requests. Please be specific.
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 MattressPortable Oxygen Concentrator - 5LPMTilt-N-Space Manual Wheelchair
Beds and Accessories (Ala Carte)

Semi Electric Hospital Bed with 1/2 Rails and MattressFull Electric Hospital Bed with 1/2 Rails and MattressBed Rails, Full (if added after patient has the bed, patient must be out of bed for install)Bed Rails, Half (2nd Set for bottom of the bed, Additional Charge, patient can stay in bed for install)Trapeze Bar (Attached to Hospital Bed)Eggcrate, 4 inchAPP with MattressLow Air Loss MattressOver Bed TablePatient Lift with Sling
Mobility Items (Ala Carte)

Walker, Front WheeledWalker, RollatorWheelchair, TransportWheelchair, StandardWheelchair, Heavy DutyWheelchair, Extra Heavy DutyWheelchair, RecliningWheelchair, Elevating Legrests
Commode and Bath Items (Ala Carte)

Commode, BedsideCommode, BariatricShower Chair with BackTransfer BenchRolling Shower Chair
Respiratory Items (Ala Carte)

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

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

Hospice DME Order Form