Order dme | Circle A Pharmacy

Provider Name: *

Provider Phone Number: *

Provider Email: *

Patient Full Name: *

Patient Height: *

Patient Weight: *

Caregiver Full Name:

Caregiver Phone Number:

Location Health Assessment: *

Location Infected (by Covid, HIV,...)

No Infection

Delivery Address: *

Delivery City: *

Zip Code: *

Patient Contact Number: *

Subject: *

Delivery Options: *

Delivery

Pick up

Location of Delivery: *

Residential

Facility

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Hospital Bed:

Full Electric Bed Delta Ultra Light 1000

Semi Electric Bed Delta Ultra Light 1000

APP Med-Aire Pressure Pump & Pad

Quick N Easy Comfort Mattress

Half Length Bed Rail

Trapeze Bar

Adjustable Overbed Table

Wheelchairs:

Wheelchair with 16 inch Seat Width

Wheelchair with 18 inch Seat Width

Wheelchair with 22 inch Seat Width

Wheelchair with 24 inch Seat Width

High Strength Lightweight Wheelchair

Aluminum Transport Chair 19 inch

Full Reclining 22 inch

Lightweight Travel Rollator

Respiratory:

DeVilbiss 10 Liter Oxygen Concentrator

Dynarex Oxygen Concentrator, 0.5 to 5 Liter

Power Neb Ultra Nebulizer

Heavy Duty Suction Machine

Handheld Compressor Nebulizer

Oxygen Cylinder:

Size M6 (Set of 2)

Size E

Walker Aids:

Folding Walker with Wheels

Folding Walker No Wheels

Shower Equipment:

3 in 1 Commode

Bariatric 3 in 1 Commode

Aluminum Transfer Bench

Bath Bench

Bariatric Bath Bench

Patient Lift:

Hi-Fortune Electronic Patient Lift With Sling

Prescription:

Upload Prescription here, if you have one.

Other Equipment Required:

Include any extra DME needs or if you require multiples of the items listed above.

Extra Info:

Include additional patient details or delivery timeframe information if needed.

Submit

DME Order Form