Reorder

PATIENT INFORMATION
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Email *
example@example.com
Are you our patient placing an order for yourself? *

Yes No
If no, what is your relationship to the patient?
Are you currently in the hospital, a nursing home, hospice, or skilled nursing facility? *

Yes No
Have you ordered from any other company for the requested items in the last 6 months? *

Yes No

Would you like to receive the same supplies you received on your last order? *

Yes No
If any items such as doctor, insurance, or products have changed, please tell us what has changed and the new information:
If in Southeast Louisiana, would you be interested in any additional services DMS offers?

Therapeutic Footwear Diabetes Education/Nutrition Consult
If a DMS representative needs to reach out to you regarding your order how do you prefer us to contact you? *

Email Phone