GET SUPPLIES & SERVICE You Are Our Number 1 Priority! Patient Oxygen Supplies Order Form Patient: DOB: Street: City: State: Zip: Phone: Email: YOU WILL RECEIVE A 90-DAY SUPPLY OF WHAT YOU INDICATE BELOW TUBES, CANNULA & CONNECTORS: 4’ Oxygen Tubes with Nasal Cannulas7’ Oxygen Tubes with Nasal Cannulas14’ Oxygen Tubes with Nasal Cannulas25’ Extension Tubing & ConnectorsChristmas TreeSwivel Connectors ADDITIONAL SUPPLIES: Condensation TrapEar ProtectorsHumidifer Bottles NOTE: Products may vary from the images above based on current availability. ORDER COMPLETE BY: Name: PatientCaregiver or Othe CHANGES WITH YOUR INSURANCE? If your insurance or address changes, please notify us so that we can update your records to avoid any lapse in service and ensure that you do not get billed instead of your insurance. SUBMIT IF YOU DO NOT RECEIVE AN ORDER CONFIRMATION IN 48 HOURS, PLEASE CALL US AT 501-401-6837 For Repair, Questions or Changes 501-401-6837 Thank you for choosing American Medical Rentals as your Oxygen Provider 6701 West 12th St, Suite 14 | Little Rock, AR 72204 | Office (501) 376-6922 | After Hours (800) 388-7246 Don’t see what you need, or just have questions? Give us a call. 800.388.7246
