man hugging grandson
Oxygen Travel Information Form
Patient Name:
Patient SSN:
Destination Address:
Destination City:
Destination State:
Destination Zip:
Is it a home or a hotel?
Destination Phone #:
Mode of Transportation:
Airline:
Flight #:
Arrival Date:
Arrival Time:
Departure Date:
Departure Time:
Person who will pick up equipment:
   

Equipment needed

Qty

         Item
 Oxygen Concentrator
 M24 (E) Cylinder
 M6 (B) Cylinder
 Regulator
 Conserver
 M24 (E) Cylinder Cart
 M6 (B) Cylinder Bag
 50' Cannula
 25' Cannula
4' Cannula
   


2005 Copyright Extrakare. All rights reserved.

Home      |     Contact  Us     |     Directions     |     Privacy Policy