Johnson Drug & Home Medical - Respiratory Services Order Form

Use this form to order Respiratory Supplies from the New Bridge store only

714 New Bridge St.
Jacksonville, NC 28540
Phone: 910.347.5185
Fax: 910.347.9298

 
To order online, simply complete the Request form below.

* INDICATES REQUIRED FIELD

Your Information

First Name*:   Last Name*:  

Date of Birth*:

Street Address*:   City*:  

State*: Zip*:

Phone number where someone can reach you during the day*:

Insurance Information

Insured Name*:    Primary Insurance Carrier*:

Policy / Group #*:    Member #:

Secondary Insurance Carrier:

Policy / Group #:    Member #:

Respiratory Services

Home Oxygen w/portable

LPM 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0 5.5 6.0 6.5 7.0

O2 Saturation % or PO2    mmHg

At rest at Exercise    at Sleep

CPAP Settings: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 cm H2O

BiPAP Settings: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 / 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 cm H2O

       Oxygen Included: Yes   No     LPM 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0 5.5 6.0 6.5 7.0

Overnight Pulse Oximetry

Sleep Apnea Link

Nebulizer   Medications:  Select Albuterol 2.5 mg Xopenex 1.25 mg Ipratropium 0.5 mg Albuterol 2.5 mg / Ipratropium 0.5 mg Xopenex 1.25 mg / Ipratropium 0.5 mg Other  Dosage/Frequency:

Other:

Delivery Instructions

Location:   Residence    Facility    Other

Address:    Room #:

City:    Contact Phone:

*Confirmation Preference: Phone   E-mail

Please include any special instructions in the box below: