Your-medical-store.com

Book an Appointment to Get your Durable Medical Equipment (DME)
Your Name*

First NameLast Name
Yes or No: I have already purchased my desired DME product and now looking to get insurance to reimburse

YESNO
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Date of Birth:*

MonthDayYear
Date
Your Home Address (This is the address on file with your insurance plan.)*

1234 Main St.

Apartment, Suite, etc. (optional)

CityState / Province

Postal / Zip Code
Your Mailing Address (This is the address where your product(s) should be delivered.) *IF THIS ADDRESS IS THE SAME AS ABOVE, PLEASE LEAVE THIS SECTION BLANK.

1234 Main St.

Apartment, Suite, etc. (optional)

CityState / Province

Postal / Zip Code
Will you be using Insurance or Self-Pay?
Insurance Card, if using insurance. (front and back):

Cancelof
Upload a PDF or JPEG copy of your medical records (front & back):

Optional
Cancelof
What is the SKU of the DME product you want from Your-medical-store.com?*
Your Message
Before you finish this form, we wanted to share the exciting news. My Virtual Physician now has its own app. Available now on Android phones/tablets from the Google Play Store. Click here to download https://play.google.com/store/apps/details?id=com.lifehealthwalletusa.lifehealthwalletusa&hl=en&gl=US
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Book an Appointment to Get your Durable Medical Equipment (DME)