Reorder Urology Supplies

Reorder Urology Supplies Form

IMPORTANT! To process your reorder request, all fields below must be completed. A reorder specialist will only reach out to you if you have had a change in insurance or treating physician OR if it is determined that you currently don’t qualify for a reorder based on insurance rules and regulations.

Patient First Name*

Patient Last Name*

Patient Phone Number*

Patient Email*

Shipping Address*

Shipping City*

Shipping State*

Postal Code

Have you had a change in Medical Insurance over the last 3 months?

Has your treating physician changed within the last 3 months?

Do you currently receive in home health care or in home physical therapy?

Are you currently receiving care at home through a Home Health or Hospice agency?

Are you currently receiving inpatient care through a hospital, skilled nursing or rehab facility?

How many Men’s Liberty Units do you currently have on hand?

How many Bed Bag’s do you currently have on hand?

What products would you like to reorder?

Men's Liberty :

Bed Bags:

KindKlamp:

Authorization

I authorize Wound Care Resources to contact me by phone and leave voicemail related to Men’s Liberty.

Opt-In (SMS)

I agree to get marketing and account notifications from Wound Care Resources by text message. Consent is not a condition of purchase. Message frequency varies. Standard message and data rates may apply.

Please verify your request*

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Reorder Urology Supplies

Reorder Urology Supplies

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