Medical Supplies, Wound Care Dressings, Ostomy & Diabetic Supplies, Enteral Nutrition, DME Billing, Wound Care & Nutritional Consultation
 


Essential Medical Solutions Order Form - simple, organized and easy to use.

Click below to print out order form. Fax with patient demographics to (877) 231-3088.

OR

Call (877) 278-1079 toll free to order by phone.


Click on the topics below for more detailed information.
Filling Out the Essential Medical Solutions Order Form
Faxable Order Form
Common ICD9 Codes

Wound Information
Spaces must be filled in and correct choices marked (circled on paper form or checked on emailable form). This information is required by Medicare and other insurance companies.

Customized Dressing Order
Style, drainage and units/month are given for your information only and are determined by Medicare. Our office will send the correct dressing size based on the wound measurements given. Drainage and units/month guidelines indicate which products you may combine based on drainage and how often the dressing needs to be changed.

Place check marks going down the product list beside the dressings desired for each numbered wound site.

Signatures
EMS must have the patient's signature as well as the physician's name, signature and NPI number in order to bill insurance. EMS will obtain doctor and patient signatures for orders emailed to us from this site.

 
It is imperative to determine if a nurse/physical therapist is coming into the home for ANY reason.
Patient is receiving home health OR outside assistance in the home: Yes No
Contact Email:   (We will send confirmation upon receiving your order)
Patient Name:   Patient Phone:
Doctor Name:   Doctor Phone:
Facility Name:   Doctor Fax:
Your Name (Clinician):   Date:
REQUIRED WOUND INFORMATION
Mark all choices and fill in spaces - all fields are required for each wound section per wound

Wound Stage
Wound 1
II III IV
P F Un
Wound 2
II III IV
P F Un
Wound 3
II III IV
P F Un
Wound 4
II III IV
P F Un
ICD9 Code
Size LxWxD
in cm
L W D L W D L W D L W D
Location
ex: L lower leg
Drainage min mod heavy min mod heavy min mod heavy min mod heavy
Ever Debrided? yes no yes no yes no yes no
Duration of Need 30 60 90 30 60 90 30 60 90 30 60 90
Frequency qd qod wkly qd qod wkly qd qod wkly qd qod wkly
 
 
CUSTOMIZED DRESSING ORDERS
Please check all products you wish to receive, for up to 3 wounds
Wound
1    2    3    4
Product Style Drainage
Requirement
Units/Mo.
Requirement
Calcium Alginate 2x2, 4x5, 3/4x12 mod-heavy up to 30
Silver Alginate 2x2, 4x5, 3/4x12 mod-heavy up to 30
Medihoney Alginate 2x2, 4x5, 3/4x12 mod-heavy up to 30
Anasept Gel 3 oz tube no-min 3 oz
Multidex Gel 3 oz tube no-min 3 oz
Silver Sept Gel 3 oz tube no-min 3 oz
Hydrofera Blue 2x2, 4x4 mod-heavy up to 12
Collagen 2x2, 4.34 sq in any up to 12
Non-Adherent Dressing 3x3, 3x8 any up to 30
Transparent Film 2x3, 4.25x4.25, 6x8 no-min up to 12
ABD Pad 5x9, 8x10 mod-heavy up to 30
Algidex AG Foam 2x2, 4x5 mod-heavy up to 12
Bordered Foam 1.6x2, 3x3, 4x4, 6x6 mod-heavy up to 12
Antimicrobial Gauze 4" roll any up to 30
Gauze Roll 4" bulky roll any up to 30
Conforming Gauze Roll 2", 4" any up to 30
Antimicrobial Gauze Sponge 2x2, 4x4 any up to 30
Paper Tape 1", 2", 3" any 2 rolls/wound
Transparent Tape 1", 2", 3" no-min 2 rolls/wound
Silk Tape 1", 2", 3" any 2 rolls/wound
Retention Tape 2", 4", 6" any 1 roll/wound
 
 
The order form above includes our most frequently ordered products. Please click the Products button for our complete selection.

If you prefer a certain brand or product, please list it here. If we cannot provide what you have requested, we will contact you immediately.

Available for purchase only - no S&H with above order
Check below if you would like your patient to receive this product. This item is not billable to insurance. We will contact your patient for billing and payment information.

ANASEPT SPRAY 8 oz pump: $11 12 oz trigger: $14
 
Click below to print out order form. Fax with patient demographics to (877) 231-3088.

OR

Call (877) 278-1079 toll free to order by phone.


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