8207 Market St.
Wilmington, NC 28411
Phone: 910.626.2988
Fax: 910.686.3017

To order online, simply complete the Request form below.

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Your Information

First Name*: Last Name*:

Date of Birth*:

Street Address*: City*:

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Insurance Information

Insured Name*: Primary Insurance Carrier*:

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Secondary Insurance Carrier:

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Durable Medical Equipment

Wheelchairs Power Wheelchair Lightweight Wheelchair Standard Wheelchair Transport Chair	Wheelchair Accessories Brake Extension Seat Belt Anti-Tippers Cushion
Semi-Electric Hospital Bed	Bed Accessories Trapeze Bar Over Bed Table
Mobility Aids Lift Chair Walker w/wheels Walker w/seat and brakes Patient Lift
Bathroom Needs Commode Shaver chair Shower stool Transfer bench
Miscellaneous Compression stockings

Delivery Instructions

Location: Residence Facility Other

Address: Room #:

City: Contact Phone:

*Confirmation Preference: Phone E-mail

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