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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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_row module_id=”intake_form_3″ module_class=”intake_form intake_form_3 d-none” _builder_version=”4.14.7″ _module_preset=”default” custom_margin=”20px||20px||false|false” 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=”{}”]

ORDERING PHYSICIAN 

[/et_pb_text][et_pb_contact_form captcha=”off” submit_button_text=”Next” 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%” custom_margin=”||0px|||” global_colors_info=”{}”][et_pb_contact_field field_id=”Names” field_title=”Physician Names” fullwidth_field=”on” _builder_version=”4.14.7″ 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=”npi” field_title=”NPI #” fullwidth_field=”on” _builder_version=”4.14.7″ 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=”Email” field_title=”Email” field_type=”email” fullwidth_field=”on” _builder_version=”4.14.7″ _module_preset=”default” global_colors_info=”{}”][/et_pb_contact_field][et_pb_contact_field field_id=”country” field_title=”Select Country” field_type=”select” select_options=”%91{%22value%22:%22United States%22,%22checked%22:0,%22dragID%22:-1},{%22value%22:%22Canada%22,%22checked%22:0,%22dragID%22:0}%93″ fullwidth_field=”on” _builder_version=”4.14.7″ width=”33%” custom_css_main_element=”max-width: 33.3%;||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” custom_css_main_element_last_edited=”on|phone” custom_css_main_element_phone=”width: 100%;” custom_css_main_element_tablet=”max-width: 33.3%;||float:left;||clear: none !important;”][/et_pb_contact_field][et_pb_contact_field field_id=”state” field_title=”State” min_length=”2″ max_length=”35″ _builder_version=”4.14.7″ width=”33%” custom_css_main_element=”max-width: 33.3%;||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” custom_css_main_element_last_edited=”on|phone” custom_css_main_element_phone=”width: 100%;” custom_css_main_element_tablet=”max-width: 33.3%;||float:left;||clear: none !important;”][/et_pb_contact_field][et_pb_contact_field field_id=”city” field_title=”City” _builder_version=”4.14.7″ width=”33%” custom_css_main_element=”max-width: 33.3%;||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” custom_css_main_element_last_edited=”on|phone” custom_css_main_element_phone=”width: 100%;” custom_css_main_element_tablet=”max-width: 33.3%;||float:left;||clear: none !important;”][/et_pb_contact_field][et_pb_contact_field field_id=”address_1″ field_title=”Addres Line 1″ min_length=”5″ max_length=”15″ _builder_version=”4.14.7″ 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” button_two_bg_color__hover_enabled=”off”][/et_pb_contact_field][et_pb_contact_field field_id=”address_2″ field_title=”Address line 2″ max_length=”150″ required_mark=”off” _builder_version=”4.14.7″ width=”33%” 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” button_two_bg_color__hover_enabled=”off”][/et_pb_contact_field][et_pb_contact_field field_id=”zip_code” field_title=”Postal/Zip Code” min_length=”3″ max_length=”12″ allowed_symbols=”alphanumeric” fullwidth_field=”on” _builder_version=”4.14.7″ 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_form][et_pb_button button_text=”Previous” module_id=”prev_button_2″ module_class=”prev_button prev_button_2″ _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: -55px !important;” locked=”off” global_colors_info=”{}”][/et_pb_button][/et_pb_column][/et_pb_row][et_pb_row module_id=”intake_form_4″ module_class=”intake_form intake_form_4 d-none” _builder_version=”4.14.7″ _module_preset=”default” custom_margin=”20px||20px||false|false” 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=”Next” 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%” global_colors_info=”{}”][et_pb_contact_field field_id=”primary_insurance” field_title=”Primary Insurance” min_length=”5″ max_length=”15″ _builder_version=”4.14.7″ 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” button_two_bg_color__hover_enabled=”off”][/et_pb_contact_field][et_pb_contact_field field_id=”primary_insurance_no” field_title=”Insurance No:” min_length=”5″ max_length=”15″ _builder_version=”4.14.7″ 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” button_two_bg_color__hover_enabled=”off”][/et_pb_contact_field][et_pb_contact_field field_id=”seconday_insurance” field_title=”Secondary Insurance” max_length=”55″ required_mark=”off” _builder_version=”4.14.7″ 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” button_two_bg_color__hover_enabled=”off”][/et_pb_contact_field][et_pb_contact_field field_id=”secondary_insurance_no” field_title=”Insurance No:” max_length=”55″ required_mark=”off” _builder_version=”4.14.7″ 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” button_two_bg_color__hover_enabled=”off”][/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_row module_id=”intake_form_5″ module_class=”intake_form intake_form_5 d-none” _builder_version=”4.14.7″ _module_preset=”default” custom_margin=”20px||20px||false|false” 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

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