New Patient Information

Questions?

We are happy to help you fill this out:

Call 800-883-1549
Text (517) 657-5223

Patient information

First name

Last name

Date of birth

Gender

Female Male

Height (for example 5’ 6”)

Weight (lbs)

Street address

City

State

ZIP

Mobile phone

Home phone

Work phone

Email address

Employer

Emergency contact name

Emergency contact phone

What are you being fitted for? (check all that apply)

Compression pump

Ready-to-wear garments

Custom garments

Night garments

Compression wraps

Not sure yet

Garment set(s) required (check all that apply)

Upper extremity – left

Upper extremity – right

Lower extremity – left

Lower extremity – right

Trunk

Chest

Head and neck

How did you hear about us?

Physician Therapist Internet Friend Advertisement Other

If other, please tell us

Insurance information

Type of insurance

Private health insurance Workers’ comp Medicare Medicaid Self-pay

Date of injury (workers’ comp only)

Workers’ comp claim number

Primary insurance

Insurance company

Insurance phone number

Name of policy holder

Patient’s relationship to policy holder

Self Spouse Child Other

Policy holder date of birth

Policy holder employer

Member ID number

Group number

Secondary insurance (if you have one)

Insurance company (if any)

Insurance phone number

Name of policy holder

Patient’s relationship to policy holder

Self Spouse Child Other

Policy holder date of birth

Policy holder employer

Member ID number

Group number

Optional: photos of your insurance cards (front and back) and photo ID

Add file

Please upload a file

Prescriber information

Prescriber’s name

NPI (if known)

Clinic name

Clinic phone

Clinic fax

Clinic address

City

State

ZIP

Therapist / facility information (if any)

Therapist’s name

Facility / clinic name

Therapist work email

Approved to email documents to the therapist?

Yes No

Therapist phone

Therapist fax

Facility address

City

State

ZIP

Authorization

By checking the box and typing my name below, I confirm the information above is accurate. I authorize Midwest Compression to contact my insurance company, my prescriber and the providers listed above to verify my coverage and obtain the documentation needed for my order.

I agree to the authorization above

Type your full name (patient or authorized representative)

Today’s date

If signing for the patient, your relationship to the patient

Your information will be encrypted.