Place an order — two easy ways

We take calls 24/7, or complete the smart form below — it asks only what's needed for your item, and a real person takes it from here.

📞 Call 24/7: (607) 270-2777

Smart order & request form

🔒 HIPAA-protected. Your information is used only to fulfill your request and is protected under HIPAA. We never sell your data. Read our Notice of Privacy Practices.

Your order reference: — (keep this handy if you call us)

Who is this for?

Myself A loved one A patient in my care A facility

About the patient's situation

Current care setting

Facility nameDischarge date

Discharge planner / case managerTheir phone

Currently receiving home health / home care?

Yes No

Home health agency name

Will a caregiver be present at delivery?

Yes No

Caregiver nameCaregiver phone

Has the patient used this type of equipment before?

Yes No

Delivery access notes (stairs, elevator, gate code, parking) Primary reason / diagnosis for the equipment (optional)

What you need

What do you need? Describe it (item, supplies, or service) How would you like to pay / bill?

Insurance billing requires a doctor's prescription — we can help obtain it.

Do you already have a prescription?

Yes No — please help

Prescribing doctor / clinicDoctor phone

A few workers' comp details help us bill correctly.

Claim #Date of injury

Insurance carrier / adjusterAttorney (if any)

✓ Good news — no prescription needed for most private-pay items.

Patient height Patient weight

Steps or stairs at the entrance?

Yes No

Is fall safety a concern (low bed needed)?

Yes No

Recent sleep study or oxygen test / prescription?

Yes No

Currently using any equipment? (brand / type)

Which limb(s)? Have measurements?

Wound location Supply frequency

Optional resupply

Meter or CGM? Shoe size (if shoes)

Body part Left / right / both

Would you like a fitting / evaluation?

Yes No

Type of residence What to install / assess?

Tip: text photos of the space to (607) 270-2777 to speed up your quote.

Child's age Child's height / weight

When do you need it? Delivery location Street address

City State

ZIP code White-glove in-home setup?

Yes No

Your name

PhoneEmail

Best way to reach you Best time

Anything else we should know? Upload prescription, insurance card, or photos (optional)

🔒 Files are transmitted securely — please only upload documents you're comfortable sharing.

Thank you! Secure online submission is being finalized — please call us 24/7 at (607) 270-2777 and we'll complete your order right away.

A prescription is only needed for insurance-billed items — we can help obtain it. Prefer to talk? Call 24/7 at (607) 270-2777.