Physician Order Form

1116 E. Houston Street 1010 Ayers Street

San Antonio, TX 78205 Corpus Christi, TX 78404

(210) 226-1482 tel (361) 883-5701 tel

(210) 299-1670 fax (361) 888-6420 fax



Physician Order Form



Your Name: ______________________________________________________ Your Phone: _____________________________



Patient Name: ____________________________________________________ Height: _________ Weight: _________



DOB: _____/ _____/ _____ SS # : ______ /_____ / _______ Male Female Prognosis: Poor Fair Good



Address/City/State/Zip: ____________________________________________________ Phone: __________________________



Emergency Contact: _______________________________________________________ Phone: ___________________________



Primary Ins: _____________________________ Policy #: ________________Group#:______________Phone: ________________



Secondary Ins: ___________________________ Policy #: ________________Group#:______________Phone: _______________



Dx: __________________________________________________________________Length of Need:_________mo (99=lifetime)



Oxygen  Aspirator  Nebulizer  CPAP  BiPAP

Concentrator  Suction Catheter  Neb Kits Cm H2O: ________________

Portable Conserver Fr: ________ Medication: Mask:  Nasal  Full Face

O2 Sat: __________________  Yankauer: Adult  Pedi __________________ Ramp: ____________________

Test Date: ________________ 50 psi Compressor  Delay: ____________________

ABG: _______% Trach:  Yes  No  O2 bleed in at _________lpm

Lpm: ____________________   Date of Sleep Study: ________

Hrs/day: _________________   I/E (BiPAP/autotitrate): _________

 

Cannula Mask



Wheelchairs Rehab & Power Wheelchairs Wheelchair Accessories Hospital Bed & Accessories

Standard Custom Ultra Lt Wt Positioning Cushion Standard Semi-Electric

Lightweight (Lt Wt) Custom Rehab Power Elevating Leg Rests Bariatric

Heavy Duty Standard Power Brake Extensions Trapeze Bar

High Strength Lt Wt Scooter (POV) Seat Belt APM/Air Loss Mattress

Bariatric Anti-Tippers Gel Overlay

Reclining Back Patient Lift





Intermittent Catheters Vacuum Erection Device Enteral Nutrition Rollator

Fr: ________________ Formula: __________________ Walker w/ wheels

Length: ____________ Incontinence Supplies  TENS Unit

Qty/Mo: ___________ Adult Diapers  Pump—cc/hr_____________ Bedside Commode

Straight w/ Lubricant Underpads hr/day ___________ Lift Chair

Antibacterial Wipes  Bolus—Cans/day _________ Other: _______________

Hydrophilic Briefs  Gravity—Cans/day _______

Coude Pull-Ups _________________________

Pediatric Orthotics:

Closed / Kits Diabetic Shoes _________________________

_______________________ _________________________



Special Instructions: ________________________________________________________________________________________





Physician Signature: _______________________________________________NPI#: _______________ Date: _______________