Local Medical Equipment Request

PURPOSE OF THIS FORM

This form is used to process local requests for medical furniture and equipment needed to support patient care within the Greater Cincinnati area. All requests must be submitted by a qualified medical professional and include appropriate documentation of medical necessity. The information collected ensures that the requested items are delivered accurately and in a timely manner to meet patient needs.

REQUEST FULFILLMENT

All requests are processed on a first-come, first-served basis. While every effort will be made to fulfill requests as submitted, specific medical furniture or equipment may not always be available due to inventory limitations. In such cases, alternative items of comparable function may be provided, or the request may be delayed until the requested item becomes available. Please note that once product availability is confirmed by our team via email, you or your representative will have 72 hours to pick up the item by appointment.

Questions? Please reach out to our team at [email protected].

PRACTITIONER INFORMATION

Important Notice:

This form must be completed by a licensed medical practitioner (e.g., physician, nurse, physical therapist). Patients are not permitted to fill out this form.

Practitioner Name(Required)

Prefix First Last

Name of Medical Facility / Organization Affiliation(Required)

(e.g., Christ Hospital, Cincinnati Children’s Hospital, etc.)

Practitioner Email(Required)

PATIENT INFORMATION

Patient's Full Name(Required)

First Last

Patient's Email(Required)

Patient's Phone Number(Required)

REQUEST DETAILS

Date Needed By(Required)

Requested Medical Furniture/Equipment(Required)

Please specify item(s) needed

REQUIRED DOCUMENTATION

Upload Physician/Practitioner’s Note(Required)

(File formats accepted: PDF, JPG, PNG, DOCX)

Max. file size: 600 MB.