Start Documenting Order

Please do not check items ordered until its placed with the Vendor

* Pending Insurance Verification I certify that I have received all of the equipment and supplies listed above in excellent condition. I have been properly instructed on how to use and properly take care of the equipment and supplies. I also understand that in the event that payment of my co-insurance or deductible amounts are not made by my insurance carrier(s), I will be responsible for reimbursing to Survivor Friendly any balance owed up to the allowed amount. I authorize any employee of Survivor Friendly to contact me by telephone regarding the equipment and supplies I have received, additional items or supplies that I may need, and to discuss any billing and/or accounts receivable information.