Oxygen Travel Information Form
	Patient Name: Patient SSN: Destination Address: Destination City: Destination State: Please Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware 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 Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming Destination Zip: Is it a home or a hotel? Home Hotel Please Select One 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