Hospice DME Order Form (Add on Order)
Please use this order form ONLY for patients who already have been serviced by Gammie HomeCare.
Location
*
Kauai
Maui
Lanai
Hospice Representative
*
Hospice Representative Cell Phone Number
Hospice Representative Email Address (For Confirmation - Optional)
Patient Last Name
*
Patient First Name
*
Date of Birth
*
-
Month
-
Day
Year
Date
Date of Birth
*
Delivery Urgency
*
Next Business Day
URGENT - Facility Discharge
None - Pick up at Gammie HomeCare Office
Other
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 Mattress
Portable Oxygen Concentrator - 5LPM
Tilt-N-Space Manual Wheelchair
Beds and Accessories (Ala Carte)
Semi Electric Hospital Bed with 1/2 Rails and Mattress
Full Electric Hospital Bed with 1/2 Rails and Mattress
Bed 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 inch
APP with Mattress
Low Air Loss Mattress
Over Bed Table
Patient Lift with Sling
Mobility Items (Ala Carte)
Walker, Front Wheeled
Walker, Rollator
Wheelchair, Transport
Wheelchair, Standard
Wheelchair, Heavy Duty
Wheelchair, Extra Heavy Duty
Wheelchair, Reclining
Wheelchair, Elevating Legrests
Commode and Bath Items (Ala Carte)
Commode, Bedside
Commode, Bariatric
Shower Chair with Back
Transfer Bench
Rolling Shower Chair
Respiratory Items (Ala Carte)
Oxygen Concentrator, 5 LPM
Oxygen Concentrator, 10 LPM
Portable Oxygen Concentrator - 5 LPM
Oxymask Oxygen Mask (For liter flows 1-15 LPM)
Standard Oxygen Mask (For liter flows 6+ LPM - no charge option)
Suction Unit
Suction Unit Supplies (2 canisters, 2 tubing, 2 yankauers)
Nebulizer Unit
Nebulizer Kit
Nebulizer Mask
If oxygen has been ordered, please indicate the liter flow needed:
2 LPM to 4 LPM
Other
Comments - Please notate any order specifics here.
Submit
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