Compression Patient Information
A member of the Compression Clinic will reach out with-in five business days (Monday-Friday) AFTER the completion of this form to set up an appointment for a compression fitting. Compression fittings are Monday-Friday from 8am-2pm, and last 30-45 minutes. If you have any questions please call us at 804-288-8361 ext. 134.
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Address ( Must be in the state of Virginia)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter valid phone number
Email
example@example.com
Please Select Primary Insurance
Please Select
Anthem - Commerical or Medicaid
Other
If Other, what insurance?
Please note, we may not be contracted for your medical insurance.
Please list insurance ID and group number.
ID Number (Include 3-letter prefix if applicable)
Group Number
Please upload a copy of the front and back of your insurance card. You must have a prescription in order to use your insurance.
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Please select the style of compression needed.
Calf High
Knee High
Pantyhose
Thigh with waist
Maternity
Armsleeve
Glove
Gauntlet
Compreflex
Please select the compression strength needed.
15-20
18-25-Diabetic Sock Only
20-30
30-40
40-50
50-60
Do you have a prescription for the item(s) selected above?
Yes
No
Please list your doctor's name.
First Name
Last Name
Please list your doctor's phone number.
Please enter a valid phone number.
Please list the diagnosis code or reason listed on the prescription of why this is being prescribed.
ICD-10 Code ex R60.0 (edema)
Please upload a copy of your prescription.
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