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Patient Order

* Indicates a required field
Type of Order:
Customer Information
Do you give us permission to send you text messages with updates regarding your order and/or billing status?:*

Please provide your home address.

Ordering Doctor Information

Please provide the name, contact number and address for your Ordering Doctor.

Primary Care Physician Information

Please provide the name, contact number and address for your Primary Care Physician.

Do you have a written prescription on hand for the product you are requesting?*

Please provide the name and a contact number for your Home Health Agency.

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

Please provide the name, contact number and address for your Primary Care Physician.

Do you have Secondary Insurance information?:*

Please provide the name, contact number and policy number for your secondary insurance.

Order Information
Please select the appropriate option:*
Please use the area below for any additional comments.
**By submitting this order I have ascertained that I have less than 30 days supply on hand.**
**You will receive your supplies in 7-10 business days**
A representative may be calling to discuss any additional information.

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Contact Information

375 N West St
Westerville, Ohio

PH: 614-901-2226
FX: 614-901-2228

Our Services
  • Product Information Library
  • Breathe Right & Sleep Tight
  • Traveling Oxygen Program
  • Sleep Therapy Program
  • Quick Scripts - Referral Source
  • Reorder Online - Existing Patients
Resources
  • Video Library
  • Written Education
  • Frequently Asked Questions
  • Information En Espanol
  • Patient Forms
  • Healthcare Partners
About DASCO
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  • Contact Us
  • Find A Location
  • Careers

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