New CareLinc Equipment Order

Every piece of equipment we offer is different and unique. To deliver the correct item the first time and be able to bill your insurance - we really should have a conversation about what you are looking for! Send us your contact info and we’ll call you to get started!

Patient Name*
First Last
Patient's Date of Birth*
MM
DD
YYYY
Phone*
Email*
Your Name*
First Last
If not the same as "Patient Name"
Patients Address*
Street Address Address Line 2 City State ZIP Code

PLEASE NOTE: CARELINC currently services the following states: MICHIGAN, OHIO - hospice/nursing home referrals only, GEORGIA - hospice/nursing home referrals only, NORTH CAROLINA - hospice/nursing home referrals, only, SOUTH CAROLINA - hospice/nursing home referrals only. Any out of state inquiries will not be processed and must be ordered from a local DME provider within your state. Thank you!
Equipment item(s) needed for the patient:*
Item 1 Item 2 Item 3
Do you have a prescription/referral/Dr.'s order being placed with us for the item(s)?*
Because we are a DME supplier who's able to bill to insurance, many of the items we provide, do require us to have a prescription and qualifying documentation on file first before we are able to provide you with this item. If you haven't spoken to your physician about this item, please do so before submitting this form if you will not be privately paying. If you have any questions, concerns or if you are interested in how to go about ordering in general, please feel free to ask us in the comments section below!
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Item 1	Item 2	Item 3