ChesterfieldPharmacy

Dear Chesterfield Patient:
Please take a few moments to complete this form. A Chesterfield Health Services representative will respond to your request as soon as possible. All data will be kept confidential.

Required form fields are marked with an asterick (*)

Product Information

"I am in need of..." *

Have you had any of these products before?

What Products?

How long ago did you purchase it?

Patient Information

Patient's Name:*

Your Name: (if different than above)

Patient Address:

Patient City:

Patient State:

Patient Zip:

Your Email:*

Your Phone:*

I would prefer you contact me by...

Insurance Company

Policy Number:

Insurance phone number:

My Doctor's name:

My Doctor's phone number:

My Doctor's fax number:

Do you have a prescription for these items?*

For some items, the following information
is required. Please fill them in.

My height is...

My weight is...

My hips round are...

If you have any questions please call 206-838-6071
or 1-866-438-1229

send

Bath Benches
Aluminum Canes
Aluminum Quad Canes
Aluminum Commodes
Grab Bars
Toilet Safety Rails
Handheld Shower
Capri Bladder Control Pads
Protection Plus® Disposal Underpads
Protection Plus® Classic Protective Underwear
Deluxe Standard Rollator
Two-Button, Folding Walkers

none
Bath Benches
Aluminum Canes
Aluminum Quad Canes
Aluminum Commodes
Grab Bars
Toilet Safety Rails
Handheld Shower
Capri Bladder Control Pads
Protection Plus® Disposal Underpads
Protection Plus® Classic Protective Underwear
Deluxe Standard Rollator
Two-Button, Folding Walkers

DME Information Request Form