EWMS ORDER FORM
Patient Information
Name
*
DOB
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Case ID
Height
Weight
Medical Kits (Limit 1 each per year)
Starter Kit Includes Home Medical Bag, First Aid Kit, Cushions, Sheepskin Pad, Grabber Arm, Heating Pad
Medical Kits
Please Select
Starter Kit
Home Medical Bag
First Aid Kit
Emergency Kit
Fall Prevention Kit
Incontinence
Incontinence Supplies
Rows
Quantity
Brief Insert Pads
Disposable Bed Pads - 10/pk
Body Wipes - 96/pk
Urinal (Limit 2 per month)
Pullup Briefs Quantity
Pullup Briefs Size
Select size
Small
Medium
Large
Tabbed Briefs Quantity
Tabbed Briefs Size
Select size
Small
Medium
Large
Nitrile Gloves Quantity
Nitrile Gloves Size
Select size
Small
Medium
Large
Over 300 briefs, bed pads, wipes, or gloves requires a prescription. Monthly recurring orders available.
Medical Supplies
Medical Supplies
Rows
Quantity
Alcohol Surface Wipes (Limit 3 alcohol products total per month)
Alcohol Prep Pads (Limit 3 alcohol products total per month)
Automatic BP Monitor
Manual BP Monitor
Surgical Masks - 20/pk
Saline Flush
Saline / Wound Wash
Peri Wash
Sharps Container
Paraffin Bath - Hand Wax Unit
Paraffin Wax - 6 lbs.
Grabber Arm
Standard Rectangle Heating Pad
Neck & Shoulder Heating Pad
Sheepskin Pad
Compression Socks (Prescription Required)
Thermometer Quantity
Thermometer Type
Select type
Oral
Temporal
Non-Sterile Gauze Quantity
Non-Sterile Gauze Size
Select size
2x2
3x3
4x4
Sterile Gauze Quantity
Sterile Gauze Size
Select size
2x2
3x3
4x4
Position Cushions (Select up to 3)
Rows
Quantity
Back & Seat Foam Combo
Knee
Wedge
Gel Seat
Bed Foot Support
Catheter Supplies Available By Request
Bathroom Safety
Bathroom Safety
Rows
Quantity
Shower Chair
Transfer Bench
Commode Chair
Toilet Rails
Mechanical Toilet Seat Lift
Clamp On Tub Rail
More than 3 total grab bars per year require a prescription
Raised Toilet Seat Quantity
Raised Toilet Seat Size
Please Select
Standard/Round
Elongated
Shower Grab Bar - Screw In Quantity
Shower Grab Bar - Screw In Size
Please Select
12 in
16 in
24 in
36 in
Shower Grab Bar - Suction Quantity
Shower Grab Bar - Suction Size
Please Select
12 in
16 in
Diabetic Supplies
DOL Approved Diagnosis (DX) Required
Glucose Sensors (CGMs) Available By Request
Diabetic Supplies
Rows
Quantity
Lancets - 100/bx
Test Strips
Syringes
Glucose Meter Quantity
Glucose Meter Brand
Respiratory
Respiratory
Rows
Quantity
Spirometer (Limit 1 per year)
Flutter Valve / Acapella (Limit 1 per year)
Nebulizer (Prior Auth Required)
Portable Nebulizer (Prior Auth Required)
Air Purifier (Prior Auth Required)
Oxygen Concentrator Quantity
Oxygen Concentrator Type
Please Select
Portable
Stationary
Mobility
All Non-Prior Auth Mobility Items Limit 1 Per Year
Mobility
Rows
Quantity
Grabber Arm
2 Wheel Walker - No Seat
4 Wheel Rollator - With Seat
Quad Cane
Single Point Cane
Patient Lift (Prior Auth Required)
Lift Chair (Prior Auth Required)
Power Scooter (Prior Auth Required)
Power Wheelchair (Prior Auth Required)
Manual Wheelchair (Prior Auth Required)
Transport Chair (Prior Auth Required)
Beds / Mattresses / Accessories
Trapeze Bars, Bed Side Table, & All Mattresses & Hospital Beds Require Prior Authorization
Beds & Accessories
Rows
Quantity
Alternating Pressure Pad
Low Air Loss Mattress
Gel Pressure Mattress
Hospital Bed (Twin XL Standard)
Low Air Loss Therapy Bed
Trapeze Bar
Bed Side Table
Bed Foot Support
Half Length Bed Rails Quantity
Bed Rail Type
Please Select
Standard Bed (Slides Under Mattress)
Hospital Bed (Attached to Bed)
Nutritional Supplements
All Supplements Require Prior Authorization
Type of Protein Supplement
Number of Drinks Per Day
Type of Electrolyte Supplement
Other
Medical Justification
Diagnostic (DX) Code
Medical Justification
*
Other Requests
Other Requests / Comments
Our team will gather all required paperwork.
If the item requires a Prescription, Justification Form, or Prior Authorization, we will work directly with the patient's provider.
If additional information is required, our team will reach out within 24–48 hours.
For questions, contact: orders@ewmsmedical.com 801.841.4490 | Ext: 1105
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