Service Request Form

IMPORTANT! We do not use your phone number collected on this form for SMS messaging.  This number will only be used to contact you via phone if you request that contact method.

 

• Select a Location * Rochester, MN Asheville, NC Aurora, IL Austin, TXBuffalo, MNChicago, ILCincinnati, OHCleveland, OH Columbus, OHDallas, TXEau Claire, WIFaribault, MNFort Lauderdale, FLGrand Rapids, MIHouston, TXIndianapolis, IN Lexington, KYMadison Heights, MIMilwaukee, WI Minneapolis, MNNashville, TN - Branch Nashville, TN- CorporateOrlando, FL Portage, IN - WarehouseRancho Cucamonga, CASan Antonio, TXSan Jose, CASanta Rosa, CASpokane, WAStockton, CATacoma, WATacoma, WATampa, FLTuscaloosa, ALVisalia, CAWaite Park, MN
• First Name *
• Last Name *
• DOB *
• Address 1 *
• Address 2
• City *
• State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware DC Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
• Zip Code *
• Preferred Phone # *
• Phone * Cell Phone Home Phone
• Email Address *
• Are you an existing Reliable Medical Customer?

  Are you an existing Reliable Medical Customer? *

  Yes No

• Would you like insurance to be billed for repairs?

  Would you like insurance to be billed for repairs? *

  Yes No

• What is your primary insurance? *
• ID Number *
• If you have a secondary insurance provider, what is their name?
• ID Number

• What piece of equipment needs to be repaired? *
• What is your preferred appointment method? * In Home In Office/Store Drop Off