intake

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At ARTSYVE MEDI SUPPLIES, our extensive lines of medical equipment is dependable and include innovative features needed in the modern medical environment — at economical prices that fit nearly any budget. Fill out our intake form to find out if you qualify for total coverage of your medical supplies.

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BENEFICIARY

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USE OF REPRESENTATIVE

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ORDERING PHYSICIAN

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custom_css_main_element=”float:left;||width: 50%;||clear: none !important;” global_colors_info=”{}” button_text_size__hover_enabled=”off” button_one_text_size__hover_enabled=”off” button_two_text_size__hover_enabled=”off” button_text_color__hover_enabled=”off” button_one_text_color__hover_enabled=”off” button_two_text_color__hover_enabled=”off” button_border_width__hover_enabled=”off” button_one_border_width__hover_enabled=”off” button_two_border_width__hover_enabled=”off” button_border_color__hover_enabled=”off” button_one_border_color__hover_enabled=”off” button_two_border_color__hover_enabled=”off” button_border_radius__hover_enabled=”off” button_one_border_radius__hover_enabled=”off” button_two_border_radius__hover_enabled=”off” button_letter_spacing__hover_enabled=”off” button_one_letter_spacing__hover_enabled=”off” button_two_letter_spacing__hover_enabled=”off” button_bg_color__hover_enabled=”off” button_one_bg_color__hover_enabled=”off” 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custom_padding=”20px|20px|20px|20px|true|true” custom_css_main_element=”background: #fff !important;||z-index: 10;||” border_radii=”on|10px|10px|10px|10px” box_shadow_style=”preset1″ box_shadow_color=”rgba(0,0,0,0.15)” global_colors_info=”{}”][et_pb_column type=”4_4″ _builder_version=”4.14.7″ _module_preset=”default” global_colors_info=”{}”][et_pb_text _builder_version=”4.14.7″ _module_preset=”default” text_font=”Alata||||||||” header_font=”|600|||||||” global_colors_info=”{}”]

INSURANCE DETAILS

[/et_pb_text][et_pb_contact_form captcha=”off” submit_button_text=”Add” _builder_version=”4.14.7″ _module_preset=”default” _unique_id=”69f1f00f-5df3-44d5-a381-f68220804591″ custom_button=”on” button_icon=”L||divi||400″ button_icon_placement=”left” button_on_hover=”off” button_custom_margin=”15px||||false|false” custom_margin=”||||false|false” hover_enabled=”0″ global_colors_info=”{}” sticky_enabled=”0″][et_pb_contact_field field_id=”product_name” field_title=”Enter product name” _builder_version=”4.14.7″ custom_css_main_element=”width: 65% !important;||float:left;||clear: none !important;” global_colors_info=”{}” button_text_size__hover_enabled=”off” button_one_text_size__hover_enabled=”off” button_two_text_size__hover_enabled=”off” button_text_color__hover_enabled=”off” button_one_text_color__hover_enabled=”off” button_two_text_color__hover_enabled=”off” button_border_width__hover_enabled=”off” button_one_border_width__hover_enabled=”off” button_two_border_width__hover_enabled=”off” button_border_color__hover_enabled=”off” button_one_border_color__hover_enabled=”off” button_two_border_color__hover_enabled=”off” button_border_radius__hover_enabled=”off” button_one_border_radius__hover_enabled=”off” button_two_border_radius__hover_enabled=”off” button_letter_spacing__hover_enabled=”off” button_one_letter_spacing__hover_enabled=”off” button_two_letter_spacing__hover_enabled=”off” button_bg_color__hover_enabled=”off” button_one_bg_color__hover_enabled=”off” button_two_bg_color__hover_enabled=”off”][/et_pb_contact_field][et_pb_contact_field field_id=”product_quantity” field_title=”Quantity” allowed_symbols=”numbers” _builder_version=”4.14.7″ hover_enabled=”0″ custom_css_main_element=”max-width: 20%;||float:left;||clear: none !important;” global_colors_info=”{}” button_text_size__hover_enabled=”off” button_one_text_size__hover_enabled=”off” button_two_text_size__hover_enabled=”off” button_text_color__hover_enabled=”off” button_one_text_color__hover_enabled=”off” button_two_text_color__hover_enabled=”off” button_border_width__hover_enabled=”off” button_one_border_width__hover_enabled=”off” button_two_border_width__hover_enabled=”off” button_border_color__hover_enabled=”off” button_one_border_color__hover_enabled=”off” button_two_border_color__hover_enabled=”off” button_border_radius__hover_enabled=”off” button_one_border_radius__hover_enabled=”off” button_two_border_radius__hover_enabled=”off” button_letter_spacing__hover_enabled=”off” button_one_letter_spacing__hover_enabled=”off” button_two_letter_spacing__hover_enabled=”off” button_bg_color__hover_enabled=”off” button_one_bg_color__hover_enabled=”off” button_two_bg_color__hover_enabled=”off” sticky_enabled=”0″][/et_pb_contact_field][/et_pb_contact_form][et_pb_text _builder_version=”4.14.7″ _module_preset=”default” global_colors_info=”{}”]

ID	Details	Quantity	Action
1	Product name SKU: AMCCSD43443	1

[/et_pb_text][et_pb_contact_form captcha=”off” submit_button_text=”SUBMIT” module_class=”intake_form_step” _builder_version=”4.14.7″ _module_preset=”default” _unique_id=”3ce3f87b-a611-4a30-8ba0-bb4695ad87b4″ custom_button=”on” width=”100%” hover_enabled=”0″ global_colors_info=”{}” sticky_enabled=”0″][et_pb_contact_field field_id=”accept_tems_” field_title=”Your personal data will be used to process your order, support your experience throughout this website, and for other purposes described in our privacy policy.” field_type=”checkbox” checkbox_options=”%91{%22value%22:%22 I have read and agree to the website *%22,%22checked%22:0,%22dragID%22:-1,%22link_url%22:%22/terms-of-service/%22,%22link_text%22:%22Terms and Conditions%22}%93″ fullwidth_field=”on” _builder_version=”4.14.7″ hover_enabled=”0″ custom_css_main_element=”||clear: none !important;” global_colors_info=”{}” button_text_size__hover_enabled=”off” button_one_text_size__hover_enabled=”off” button_two_text_size__hover_enabled=”off” button_text_color__hover_enabled=”off” button_one_text_color__hover_enabled=”off” button_two_text_color__hover_enabled=”off” button_border_width__hover_enabled=”off” button_one_border_width__hover_enabled=”off” button_two_border_width__hover_enabled=”off” button_border_color__hover_enabled=”off” button_one_border_color__hover_enabled=”off” button_two_border_color__hover_enabled=”off” button_border_radius__hover_enabled=”off” button_one_border_radius__hover_enabled=”off” button_two_border_radius__hover_enabled=”off” button_letter_spacing__hover_enabled=”off” button_one_letter_spacing__hover_enabled=”off” button_two_letter_spacing__hover_enabled=”off” button_bg_color__hover_enabled=”off” button_one_bg_color__hover_enabled=”off” button_two_bg_color__hover_enabled=”off” sticky_enabled=”0″][/et_pb_contact_field][et_pb_contact_field fullwidth_field=”on” _builder_version=”4.14.7″ _module_preset=”default” field_id=”product_list” field_title=”Product List” field_type=”text” custom_css_main_element=”display: none !important;” hover_enabled=”0″ sticky_enabled=”0″][/et_pb_contact_field][et_pb_contact_field fullwidth_field=”on” _builder_version=”4.14.7″ _module_preset=”default” field_id=”beneficiary” field_title=”Beneficiary” field_type=”text” hover_enabled=”0″ sticky_enabled=”0″ custom_css_main_element=”display:none !important;”][/et_pb_contact_field][et_pb_contact_field fullwidth_field=”on” _builder_version=”4.14.7″ _module_preset=”default” field_id=”use_of_representative” field_title=”Use of representative” required_mark=”off” field_type=”text” hover_enabled=”0″ sticky_enabled=”0″ custom_css_main_element=”display:none !important;”][/et_pb_contact_field][et_pb_contact_field fullwidth_field=”on” _builder_version=”4.14.7″ _module_preset=”default” field_id=”physician” field_title=”Physician” field_type=”text” hover_enabled=”0″ sticky_enabled=”0″ custom_css_main_element=”display:none !important;”][/et_pb_contact_field][et_pb_contact_field fullwidth_field=”on” _builder_version=”4.14.7″ _module_preset=”default” field_id=”insurance” field_title=”Insurance” field_type=”text” hover_enabled=”0″ sticky_enabled=”0″ custom_css_main_element=”display:none !important;”][/et_pb_contact_field][/et_pb_contact_form][et_pb_button button_text=”Previous” module_id=”prev_button_3″ module_class=”prev_button prev_button_3″ _builder_version=”4.14.7″ _module_preset=”default” custom_button=”on” button_icon=”#||divi||400″ button_icon_placement=”left” custom_css_main_element=”float: left;||clear: none !important;||margin-top: -80px !important;” locked=”off” global_colors_info=”{}”][/et_pb_button][/et_pb_column][/et_pb_row][/et_pb_section]

BENEFICIARY

USE OF REPRESENTATIVE

ORDERING PHYSICIAN

INSURANCE DETAILS

INSURANCE DETAILS

Product name

CUSTOMER SERVICES

OUR POLICIES

SUBSCRIBE NEWSLETTER