Equipment Request Form

We've moved!!

All equipment will now be picked up and dropped off by appointment at our Columbia, MD location:
7125 Riverwood Drive, Suite D1 Columbia MD 21046

* Indicates required field

Name of Person Filling out Request *

First

Last

Relationship to Child *

Name of Parent or Legal Guardian (if not above) *

First

Last

Email for Parent or Legal Guardian of Child *

Phone Number for child's family *

Child's Name *

First

Last

Child's Date of Birth: *

Child's Address *

Line 1

Line 2

City

State

Zip Code

Country

County of Residence *

Weight of Child *

Height of Child *

Other Important Measurements: *

Ethnicity *

Did you try to get this equipment through insurance or other funding source? *

Annual Household Income: (This information is for tracking purposes only and will not affect your ability to receive equipment from us.) *

Insurance Type *

Item Number(s) That You Are Requesting *

Will your therapist (PT/OT) be fitting and instructing you in the use of this equipment? *

Yes No

Referral Source *

Name of Referring Person *

First

Last

Email or Phone Number of Person Referring *

Name of Referring Organization *

Comments or Other Information: *

Submit