Let Pelton's make it easy to refer your patients!

The following information is all we need.

If more convenient, you can also fax the information to our secure fax line at: (888) 895-1248.

1. Basic Patient Information

  • Name
  • Address
  • Phone Number
  • Height/Weight
  • Diagnosis
  • Chart Notes (if applicable to the prescription)

2. Equipment Prescribed

  • Duration of Need
  • Ordering Physician's Name

3. Discharge Information (if applicable)

  • Date
  • Time
  • Room Number
  • Home Health Agency for Continued Care (if applicable)