Hospice DME Order

Below is a list of all items available on the hospice formulary for DME. Complete the form below, check all equipment needed and click submit to order the items. (Please note: Any items not listed on this form require supervisor approval prior to ordering.)

Patient Information

Patient Name

Date of Birth

Height

Weight

Is there any urgency for this delivery? Please specify if 11th hour patient.

Contact Person at Home to Schedule Delivery

Key Information:

Supplies Needed (all that apply)

Liter Flow - Please provide liter flow if ordering a concentrator or homefill unit as noted above.

Will a Broda Chair be required?

Hip measurements REQUIRED to order a Broda Chair (Measure largest part of the hip, right to left) If a Broda Chair is not required, please type 'none'.

Hospice Nurse Name

Hospice Nurse Email