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Intake Assessment

Equipment Requested*

Employee (If Known)

Height*

Weight*

Sex

Male

Female

First name*

Middle Initial

Last name*

Phone*

Phone Type*

Mobile

Home

Work

Alternate Phone

Phone Type

Mobile

Home

Work

Email*

Permanent Address 1*

Permanent Address 2

Permanent City*

Per. State*

Permanent Zip*

Local Address 1

Local Address 2

Local City

Local State

Local Zip

Alternate Contact (Required for Insurance Orders)

Alternate Contact Relation

Alternate Contact Phone

Phone Type

Mobile

Home

Work

Doctor Name(Required for Insurance Orders)

Doctor Phone (If Known)

Primary Insurance Name (Required for Insurance Orders)

Primary Insurance Policy # (Required for Insurance Orders)

Secondary Insurance Name

Secondary Insurance Policy #

Date of Birth (Required for Insurance Orders)

Diagnosis (Required for Insurance Orders)

Is the equipment needed as the result of a fall?

Yes

No

Are there any visual, auditory, or verbal limitations?

No

Yes

Power of Attorney Name, if applicable. (Documentation Required)

I give permission for Health Aid Company, Inc and its staff to leave messages concerning the requested medical equipment on the following:

Phone

Alternate Phone

Alternate Contact Phone

Identification & Insurance Cards

Prescriptions & Medical Documentation

By typing my name, I declare that the information provided on this form is complete and correct and that I will notify Health Aid Company, Inc if any changes occur. I also authorize Health Aid Company, Inc permission to verify the information provided.*

Store Locations and Contact Information

Health Aid Medical - Tampa

4502 N Armenia Ave, Tampa, FL 33603

Phone: (813) 879-7552

Toll Free: (800) 835-8513

Fax: (813) 876-2621

Email: sales@healthaidcompany.com

Hours: M - F 9am - 5pm Saturday 9am - 12pm

Health Aid Medical - Largo

1156 Jasper Street, Largo, FL 33770

Phone: (727) 586-2995

Toll Free: (800) 831-9099

Fax: (727) 588-0899

Email: largosales@healthaidcompany.com

Hours: M - F 9am - 5pm

Health Aid Company,INC.

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Non-Discrimination Policy

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