Submit Your Request – Accredited Experts Meeting Your Medical Equipment Needs

Submit Your Request: Request New Equipment

Need new medical equipment? Fill out the form below and a Reliable Medical specialist will contact you to discuss options, verify insurance coverage, and arrange delivery.

Full Name*

Phone*

Email*

Are you contacting us on behalf of someone else?*

Yes

Name of Patient

Date of Birth

MM slash DD slash YYYY

Date of Birth

MM slash DD slash YYYY

Select Location*

Select the product you’re interested in*

Other Product*

Concent to agree to be contacted by Reliable Medical*

By submitting this form, I agree to be contacted by Reliable Medical.*

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Submit Your Request: Request Pickup

Do you have a rental product that you no longer need? Please fill out a pickup request using the form below, and we will have someone call you within 24-48 hours to schedule the pickup.

Full Name*

Phone*

Email*

Are you contacting us on behalf of someone else?*

Yes

Name of Patient

Date of Birth

MM slash DD slash YYYY

Date of Birth

MM slash DD slash YYYY

Select Location*

Select Your Product*

Other Product*

Concent to agree to be contacted by Reliable Medical*

By submitting this form, I agree to be contacted by Reliable Medical.*

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Submit Your Request: Physician Referral

Thank you for choosing Reliable Medical. If you would like to refer a patient, please fill out the referral form below. If you have any questions or would like to speak with our team, please contact us.

Contact Information

Closest Location*

Requester/Senders Information

Full Name*

Relationship to Patient*

Phone*

Email*

Patient Information

Patient's Full Name*

Phone*

Date of Birth

MM slash DD slash YYYY

Equipment Requested*

Patient Height*

Patient Weight*

Patient Diagnosis*

Other Equipment*

Insurance Information

Insurance Name*

Policy Number/ID Number

Group Number

Phone

Patient Discharge Date

DD slash MM slash YYYY

Order Notes

Upload Insurance File

Accepted file types: jpg, png, jpeg, pdf, docx, doc, Max. file size: 50 MB.

Physician Information

Physician Full Name*

Physician NPI*

Phone*

Physician Fax

Upload File

Please upload Rx, Progress Notes, and Face Sheet

Accepted file types: pdf, docx, doc, jpg, png, jpeg, Max. file size: 50 MB.

Concent to agree to be contacted by Reliable Medical*

By submitting this form, I agree to be contacted by Reliable Medical.*

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Submit Your Request: Service Requests

Are you in need of service on an existing Reliable Medical product? Please fill out the service form below and a service representative will call you to troubleshoot or dispatch a technician.

Full Name*

Phone*

Email*

Are you contacting us on behalf of someone else?*

Yes

Name of Patient

Date of Birth

MM slash DD slash YYYY

Date of Birth

MM slash DD slash YYYY

Select Location*

Select Your Product*

Other Product*

Questions/Comments*

Attach Photos

Accepted file types: jpg, png, jpeg, pdf, Max. file size: 50 MB.

Concent to agree to be contacted by Reliable Medical*

By submitting this form, I agree to be contacted by Reliable Medical.*

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Contact Us

We’re here to help with any questions about our products, orders, or services. Contact us through the form below, give us a call, or visit one of our locations. We look forward to assisting you.

Full Name*

Phone*

Email*

Address

City

State

Zip Code

Are you contacting us on behalf of someone else?*

Yes

Name of Patient

Date of Birth

MM slash DD slash YYYY

Date of Birth

MM slash DD slash YYYY

Select Location*

What is your reason for contacting us today?*

How do you prefer to be contacted?*

Phone

Text

Questions/Comments*

Concent to agree to be contacted by Reliable Medical*

By submitting this form, I agree to be contacted by Reliable Medical.*

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Submit a Request

Submit Your Request: Request New Equipment

Submit Your Request: Request Pickup

Submit Your Request: Physician Referral

Contact Information

Requester/Senders Information

Patient Information

Insurance Information

Physician Information

Submit Your Request: Service Requests

Contact Us