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Holland Medical Equipment
The Fastest Road to Recovery Goest Through Holland Medical
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Online Orders
Medical Equipment Request
Respiratory
Oxygen/Overnight Oximetry
Medical Equipment Request Form
Patient
Diagnosis
Projected Discharge Date
Facility
Height
Weight
Equipment History
Discharge Planner
Therapist(s)
Wheelchairs
Type
Standard
Standard Hemi
Lightweight
Lightweight Hemi
Lt. Wt. Super Hemi
Reclining
Size
16" Width
18" Width
20" Width
22" Width
Custom (specify below)
Custom Size
Accessories
Anti-Tippers
Seat Belt
Desk Arms
Elevating Legs
Brake Extensions
Cushions
Type
Roho
Jay
Invacare
Basic Foam
Width Size
Depth Size
Model
Mobility Devices
Type
Junior (for patient heights 4'4" to 5'3")
Adult (for patient heights 5'3" to 6'4")
Heavy Duty (for patients 300-400 lbs)
Hemi
Special Features
Leg Extensions (pts. 6'4" to 6'6")
Rolling Walker w/ Seat
Left Platform Attachment
Right Platform Attachment
Quad Cane (Sm. Base)
Quad Cane (Lg. Base)
Respiratory Products
O2 System w/ Conserving Device
Nebulizer
CPAP
Other (specify below)
Other
Bath Equipment
Bedside Commode
Drop Arm Commode
Heavy Duty Bedside Commode
Toliet Safety Frame
Raised Toilet Seat
Raised Toilet Seat w/ Arms
Shower Chair w/ Back
Shower Chair w/o Back
Clamp-On Tub Grab Bar
Hand-Held Shower
Diverter Value
Tub Transfer Benches
Plastic
Vinyl Padded
Deluxe Waterproof Padded
Left Side Arm
Right Side Arm
Miscellaneous
Hip Kit
Hospital Bed
Hydraulic Patient Lift
Trapeze
Sliding Board (specify size below)
Other (specify below)
Sliding Board Size
Other
Physician
Address
Phone
UPIN #
Date
