TLC Knee Caddy Patient Information
Foot Scooters, LLC 380 Bendel Ranch Rd New Braunfels, Texas 210-683-6480 Fax 830-885-4985
Please complete this form and Fax Back to Foot Scooters, LLC at 1-830-885-4985 PATIENT INFORMATION FORM Patient’s Name______________________________________ Patients Address __________________________________________ City ___________________State ___________Zip ___________ ______ E-mail Address___________________ Phone Home ( ______ ) ____________________ Cell ( ____ ) ________________ Primary insurance provider. ___________________________________________Date of Surgery ____ __________ Patient’s Doctor _________________________________________ City and State ___________________________ Date you want the TLC delivered__________________________ Doctors Phone Number_____________________ Right or Left leg? __________________________ Height
_________________________________________________________________
How long do you expect to be non weight bearing? _______________________________
Foot Scooters, LLC does not process insurance claims. Insurance claims are submitted “by the patient”. Ask Your Doctor about providing you with a Doctor’s Prescription & Letter of Necessity for your Knee Caddy insurance claim for reimbursement. For insurance claims use DME Code E0118 along with the TLC purchase receipt and the Doctor’s documentation.
WE are TRICARE authorized as Non-network DME. Provider ID: 900409992 Provider NPI: 1023256419 Classification: DME
I understand that it is my responsibility to follow the manufacturer’s instructions for operation and safety of the Turning Leg Caddy, and to use common sense. Children will not be allowed to use the product (unless the child is the patient). RAMM TLC, LLC and Foot Scooters, LLC assumes no liability for any injury or damages arising from the use or misuse of this product. If I have questions, I will contact Foot Scooters, LLC at 210-6836480 for assistance.
Foot Scooters, LLC
Turning Leg Caddy (TLC) Knee Caddy Purchase & Payment Authorization
PREAUTHORIZED AUTHORIZATION PAYMENT AGREEMENT FOR KNEE SCOOTER PURCHASE and SHIPPING
Complete and fax to 830-885-4985 the following: 1.This form, 2. A signed voided check for the amount of the purchase, 3. A copy of your Drivers Licenses.
I (we) hereby authorize Foot Scooters, LLC hereinafter called COMPANY, to initiate debit entries to my (our) Checking / Savings account indicated below and the bank depository named below, hereinafter called DEPOSITORY, and to debit the same to such account. NAME: Please print and sign both signature name (name(s) ) below when a joint signature is required on the Checking / Savings accounts: Print Signature(s) Names Below: 1. ______________________________________________ 2. _______________________________________________
BANK DEPOSITORY NAME:_________________________________________________________ BANK BRANCH:____________________________________________________________________ CITY ______________________________ STATE ____________ ZIP ______________________ BANK ROUTING / TRANSIT/ABA NO. ______________________________________________ (Where do I find this information?) CHECKING OR SAVINGS ACCOUNT NO. __________________________________________ (Where do I find this information?) Please attach a SIGNED and VOIDED check or withdraw slip to a blank piece of paper and FAX to 830-885-4985. The check or withdraw slip should be made out to Foot Scooters, LLC for the total amount of the Knee scooter order including shipping. Please write VOID on the check before faxing. Please e-mail ( footscooters@gvtc.com ) or call to request current shipping charges if you live more than 150 miles from San Antonio Texas. Shipping time estimated to be 2 to 4 days after acceptance of order. Shipping method and estimates based on UPS ground services. Please enter the total amount to be debited from the above account for this order $________________. The full amount will be debited from the account when processing this order.
#Unit Model Crutch holder not included Unit Price Shipping & Handling ( 2-4 Business day within 150 miles from SAT). Basket Price each
Basket
Sales Total
TLC Pathfinder $575.00 TLC Pilot
$35.00 $35.00
Y / N $25.00 Y/N
$600.00
$25.00
Accessories
1
Wheel Covers
$3.00 each or $10.00 set 0f 4
2
Crutch holder not offered for purchased unites Note: All Pricing subject to change without notice. Total
Check box if you approve no signature required on delivery of shipment. (Note: We cannot ship to a P.O. Box number) Shipping Address:_____________________________________________________________________ City____________________________________ State ________Zip Code________-________ Phone No. ________________
Signature(s): Please sign below as you would on your check / savings account to process payment for this order.
1. X _____________________________________________ Driver License Number: ____________________________ State: _________________________________ Renewal Date:______________________ 2.X _____________________________________________ Driver License Number _______________________________ State: _________________________________ Renewal Date:__________________________