Patient Information Form
NEW PATIENT
RESP.
REFERRAL DATES:
EXISTING PATIENT
DME
START DATE:
I.D.#
HOSP. ADMIT DATE:
DELIVERY DATE:
CASE INFORMATION:
Tel:
Info. Taken By:
Referred By:
Hospital/Agency:
RM/FL:
Tel:
DEMOGRAPHICS:
Patient Name:
Tel:
(last)(first)(MI)
Alt. Tel.:
Address:
Apt:#
Flr.:
City:
: State:
Zip:
SS#
DOB:
Gender:
M
F
PT. Lives Alone:
Y
N
Emergency Contact:
Tel:
Relationship:
Alt. Tel:
DIAGNOSIS:
Primary:
Code:
Secondary:
Code:
Allergies:
Latex Allergy:
Y
N
Cardiac/Renal Hx:
Diabetic:
Y
N
Ht:
Wt:
PHYSICIAN INFORMATION:
Ordering MD:
Tel.:
DEA#:
UPIN#:
Fax:
Primary Care MD:
Tel.:
DEA#:
UPIN#:
Fax:
INSURANCE:
(Non-Refundable Once Items Dispensed and Delivered to Patient)
Primary:
Subscriber Name:
Policy #:
Group#:
Employer:
Secondary Insurance:
Policy # :
Address:
Verified?:
Y
N
By:
Contact:
Tel:
Financial Agreement:
Person Informed of Financial Arrangements:
Medicare Waiver
Y
N
PATIENT NAME:
THERAPY INFORMATION:
Therapy Description:
Dose:
Frequency:
Duration:
First Dose:
Y
N
Device: Pump
Y
N
Type:
Gravity
Dial-a-flow
Present Dosing Schedule:
Time Dose Due:
Teachable:
Y
N
Liaison:
Date:
Time:
ENTERAL:
NG-Tube
G-Tube
J-Tube
Low Profile Button
Frch. Size:
Length
cm
Pump:
Y
N
Type:
Gravity:
Bolus:
Cycled:
Formula:
Cans per day:
RESPIRATORY:
OXYGEN: Liter flow:
Room air set:
NEBULIZER: Mask:
Y
N
TRACH CARE: Trach size:
Portable Suction:
Y
N
Suction Catheter:
Frch. Yankeur Handles:
MIST HUMIDIFICATION:
Bun Compressor
Trach mask
Heater
6 Ft. corrugated tubing
Large vol. nebulizer jar
Trach care kits 1 per day:
CPAP/BiPAP: Type:
Sleep Study:
Y
N
Mask size:
Settings:
ALL THERAPIES
ESTIMATED TIME OF DELIVERY:
WHERE:
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