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Welcome!

Total Health Care Plus has created a one stop shopping source for durable disability medical devices, home care devices, mobility devices, handicap medical devices and assistive medical device equipment.


postheadericon Medical Supply Request

Fill in the form below with your information and a customer service representative will be in contact soon. Thank you.
Name *
Date of Birth *
Social Security Number *
Street Address *
Address (cont.) *
City *
State *
Zip *
Work Phone *
Home Phone *
Sex *   Male

  Female
Height *
Weight *
Email *
Insurance Information
Insured’s Name *
Primary Insurance *
Phone *
Policy Number *
Group Number *
Bill To Address *
Secondary Insurance
Phone *
Policy Number *
Group Number *
Bill To Address *
Supply Information
Supplies Needed *
Quantity *
Do You Have A Prescription? *
Date on Prescription
Today’s Date: *
Time: * :

:

 
Type Your Name Here *
Electronic Signature *