VMS-Order-New-Form-2026

VMS ORDER FORM
Requester Information
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Patient Information
Name
DOB

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Case ID
Height
Weight
Medical Kits (Limit 1 each per year)
Total Care Package includes Breathe + Medical Essentials Kit, First Aid Kit, grabber arm, cushion set, back and shoulder heat pad, and sheepskin pad.
Medical Kits
Incontinence

Incontinence Supplies

Pullup Briefs Quantity
Pullup Briefs Size
Tabbed Briefs Quantity
Tabbed Briefs Size
Nitrile Gloves Quantity (Limit 3 boxes per month)
Nitrile Gloves Size
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 (Limit 1 per year)
Manual BP Monitor (Limit 1 per year)
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)

Position Cushions (Select up to 3)

Bathroom Safety

Diabetic Supplies

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)

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
Nutritional Supplements
All Supplements Require Prior Authorization
Type of Protein Supplement
Number of Drinks Per Day
Type of Electrolyte Supplement
Other
Medical Justification
Diagnosis (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@victorymedsupply.com 801-770-0520
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VMS ORDER FORM