All Forms·Corona · InlandDME@gmail.com
Inland DME

Mobility Equipment Order

1426 W. 6th St Suite 108 Corona, CA 92882 · (951) 278-1222

Patient Information

Check all that apply

Power

K0823 Power Wheelchair
E2365 U1 Battery
E0973 Adjustable Armrests
K0821 Power Scooter
E0295 Semi-Electric Hospital Bed
E0305 Hospital Bed Half Rails
E0277 Air Pressure Mattress

Manual

Wheelchair – Standard
Wheelchair – Lightweight
Wheelchair – Heavyduty
Transport Chair
Swingaway Footrests
Wheelchair Back Cushion
4-Wheel Walker / Rollator
Walker Seat
Platform Attachments
Knee Scooter
Crutches – Forearm
Crutches – Underarm
Other

Prescriber Information

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