ReOrder Form

Our family serving yours since 1987

Type of ReOrder

CPAP Supplies Pharmacy Both

Customer Information

First Name*		Last Name*
Phone No..*		Daytime/Alternate Phone No.
Email Address*		Dasco Account No.
Confirm Email*

Are you currently under the care of a Home Health Care Nurse*

Yes No

Please provide the name and a contact number for your Home Health Agency (Leave blank if No.)
	Name*	Phone*

Has your home address changed since your last order?*

Yes No

Please provide your new home address (Leave blank if No.)
	Address*
	Address 2
	City, State, Zip*

Would you like to ship the order to a temporary shipping address?*

Yes No

Please provide the address of the location you would like the order shipped (Leave blank if No.)
	Address*
	Address 2
	City, State, Zip*

Primary Care Physician Information

Has your Primary Care Physician information changed/updated since your last order?*

Yes No

	Please provide the name, contact number and address for your new Primary Care Physician. (Leave blank if No.)
	Name*			Phone No.*
	Address
	Address 2
	City, State, Zip

Insurance Information

Has your Primary Insurance information changed/updated since your last order?*

Yes No

	Please provide the name, contact number and policy number for your new primary insurance. (Leave blank if No.)
	Name*			Phone No.*
	Policy No.*			Group No.*
	Primary Insurance Billing Address
	Address
	Address2
	City, State, Zip

Has your Secondary Insurance information changed/updated since your last order?*

Yes No

	Please provide the name, contact number and policy number for your new secondary insurance. (Leave blank if No.)
	Name*			Phone No.*
	Policy No.*			Group No.*
	Secondary Insurance Billing Address
	Address
	Address2
	City, State, Zip

Re-Order Information

Please select the appropriate option*

Process same supplies and quantities as last order
Supplies and/or quantities have changed (Please Note changes in the space below)

Please use the area below to describe the changes to your order*

Please use the area below for any additional comments.

Yes! I would like an Email confirmation that my request has been received*

By submitting this order I have ascertained that I have less than 30 days supply on hand.

* Indicates a required field

**You will receive your supplies in 7-10 business days**

A representative may be calling to discuss any additional information

DASCO Home Medical Equipment

Our family serving yours since 1987

J.C.A.H.O. Accredited Since 1989
375 N. West St., Westerville, OH 43082
1-800-892-4044 / Email: info@godasco.com

site created by R. Davis

Type of ReOrder

Customer Information

Primary Care Physician Information

Insurance Information

Primary Insurance Billing Address

Secondary Insurance Billing Address

Re-Order Information

Yes! I would like an Email confirmation that my request has been received*

**By submitting this order I have ascertained that I have less than 30 days supply on hand.**

* Indicates a required field

By submitting this order I have ascertained that I have less than 30 days supply on hand.