First Name *

Last Name *

Date of birth

Phone *

Email *

Address

City *

State *

Country *

Postal Code *

I Consent to Receive SMS Notifications, Alerts & Occasional Marketing Communication from company. You can reply STOP to unsubscribe at any time.

Have you been SEEN AND TREATED by your Doctor within the last 12 months regarding your pain? *

Yes

Doctor's Name *

Doctor's City *

Doctor's State *

Doctor's Phone *

What type of Health Insurance do you have? *

Medicare Part B

Other

Medicare ID *

Make sure your insurance card looks like this:

Insurance Billing Authorization (Required) *

I request that payment of authorized Medicare and/or private insurance benefits on my behalf be made to Bridgewater Health Supplies, LLC for any services furnished to me by Bridgewater Health Supplies, LLC. I authorize any holder of medical or other information about me to release to Bridgewater Health Supplies, LLC, Medicare, and/or my private insurance, and its agents, any information needed to determine these benefits for related services.

How this helps you

✔ Saves you time and hassle—we’ll handle all the confusing claim forms
✔ Faster processing of your order
✔ In most cases, we can determine your insurance eligibility in real-time
✔ Without this, we can’t determine your insurance eligibility (required for approval)

Your Consent is Required *

I am agreeing by my electronic signature, to give Bridgewater Health Supplies, LLC, my prior affirmative express written consent and permission to call and/or send me SMS text messages at the cellphone number(s) I provided regarding my current or future orders using an automatic dialing system at any time from and after my inquiry to Bridgewater Health Supplies, LLC. This is to remain compliant with all federal, state, and Do-Not-Call telemarketing laws.

How this helps you

✔ This allows us to keep you informed about your medical supplies
✔ Send Email and/or SMS updates on your current order(s)
✔ Notify you about delivery times and order statuses

Electronic Signature / Consent to Contact (Required) *

Clear