HOME MEDICAL EQUIPMENT

1340 Floyd Ave.

Rome, NY 13440

Ph: (800) 227-2292 or (315) 339-4084

Fax: (315) 339-4134
www.nunnshme.com

FACILITY INTAKE/REFERRAL SHEET

CONTACT PERSON FIRST NAME:

__________________________________

DATE: ___________

FACILITY: ________________________________________________

NAME: _______________________________________

HEIGHT: ____________________________________

DOB: ___________________________

WEIGHT: _____________________

INSURANCE 1: ____________________________________________

INSURANCE 2: _____________________________________________

DISCHARGE DATE: ___________________________ ROOM #: _______________

EQUIPMENT ORDERED: ____________________________________________________

DX________________________________________________________________________

ORDERING DOCTOR_______________________________________________________

PATIENT CONTACT # (HERITAGE ONLY)________________________________________

*SHOULD WE PICK UP PAPER WORK UPON DELIVERY OR WILL YOU FAX IT TO US??

THANK YOU FOR YOUR ORDER!!!!!

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