Hale Makua DME Order Form
Location
*
Kahului
Wailuku
Hale Makua Representative (include name, phone number, and email)
*
Melani Campos, 808-357-2109, melani.campos@halemakua.org
Erllie Cabacungan, 808-357-2271, erllie.cabacungan@halemakua.org
Sharron Joseph, 808-281-6438, sharronj@halemakua.org
Mark Souza, 808-357-2266, mark.souza@halemakua.org
Other
Patient Last Name
*
Patient First Name
*
Patient Height (inches)
Patient Weight (lbs)
Neighborhood and Room Number
*
Delivery Urgency
*
Same business day (order must be placed by 1pm)
Next Business Day
Other
Deliver To:
*
Resident's Room
Nurses Station
Maintenance Department
Purchasing Department
Administrative Offices
Other
Additional Comments for delivery requests. Please be specific.
Standard / Heavy Duty Wheelchairs
Standard Wheelchair, 16" wide w/ footrests (250 lb. weight limit)
Standard Wheelchair, 18" wide w/ footrests (250 lb. weight limit)
Standard Wheelchair, 20" wide w/ footrests (250 lb. weight limit)
Heavy Duty Wheelchair, 20" wide w/ footrests (350 lb weight limit)
Heavy Duty Wheelchair, 22" wide w/ footrests(350 lb. weight limit)
Heavy Duty Wheelchair, 24" wide w/ footrests(350 lb. weight limit)
Extra Heavy Duty Wheelchair, 24" wide w/ footrests (450 lb. weight limit)
Topaz Bariatric Wheelchair, 26" wide w/ footrests (700 lb. weight limit)
Elevating Legrests
Wheellock Brake Extensions 6" (Pair)
If ordering a wheelchair, please select seat to floor height:
Adult 19"
Hemi 17"
Reclining Wheelchairs
16" Reclining Wheelchair w/ Elevating Legrests (300 lb. weight limit)
18" Reclining Wheelchair w/ Elevating Legrests (300 lb. weight limit)
20" Reclining Wheelchair w/ Elevating Legrests (300 lb. weight limit)
Beds and Support Surfaces
Semi Electric Hospital Bed with 1/2 Rails and Mattress (350 lb. weight limit)
Full Electric Hospital Bed with 1/2 Rails and Mattress (350 lb. weight limit)
Bariatric Full Electric Hospital Bed with 1/2 Rails and 42" Wide Mattress (600 lb. weight limit)
Trapeze Bar Attached to GHC Hospital Bed (250 lb. weight limit)
Free Standing Trapeze Bar (250 lb. weight limit)
Free Standing Bariatric Trapeze Bar (500 lb. weight limit)
APP with Mattress (250 lb. weight limit)
Gel/Foam Mattress Overlay (Purchase Only) 350 lb. weight limit
Low Air Loss Mattress (500 lb. weight limit)
Bariatric Low Air Loss Mattress, 42" wide (1000 lb. weight limit)
Patient Lift, Hydraulic (450 lb weight limit)
Patient Lift Sling, U-Shape, Divided Leg Style, Size PETITE (SM)
Patient Lift Sling, U-Shape, Divided Leg Style, Size MD
Patient Lift Sling, U-Shape, Divided Leg Style, Size LG
Patient Lift Sling, U-Shape, Divided Leg Style, Size XL
Respiratory Items
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)
Auto CPAP Unit (Use comments below to list pressure range needed)
Bilevel Unit (Use comments below to list IPAP and EPAP pressures needed)
Suction Unit (Oral)
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:
2lpm
3lpm
4lpm
Other
Comments - Please notate any order specifics here.
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