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Lymphedema & CVI Information
Great Lakes Medical Equipment Products and Services
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Mailing Address
Great Lakes Medical Equipment, Inc.
P.O. Box 1402
Jackson, MI 49204		 Phone
800-368-2364 or
517-536-7350		 Fax
517-536-0671 or
616-949-5210

For your convenience, you may fill out the patient information form below,
print it, then fax it to our confidential fax line.

Patient Information
First Name
Last Name
Email
Address
include City, State, Zip
Phone
Date of Birth
Diagnosis
History
   
Physician Information
First Name
Last Name
Address
include City, State, Zip
Phone
UPIN
Contact
Speciality
Primary MD
Primary MD Phone
   
Private Insurance (Primary or Secondary)
Insurance
Group #
ID #
Address
include City, State, Zip
Phone
Name of Insured
Date of Birth
Medicare #
SS #
Insured's Employer
Employer's Phone
   
Requested Materials
Lympha Press® Lymphedema Pump CircAid
Compression Garments  
   
   
   
DISCLAIMER - This site is designed for educational and promotional purposes only and is not engaged in rendering medical advice or professional services. The information provided here should not be used for diagnosing or treating a health problem or disease. It is not a substitute for professional care. If you have, or suspect you may have, a health problem, you should consult your physician. This information is provided in good faith, but no warranty can be made for its accuracy. The opinions expressed herein are exclusively ours. If you have any questions, please contact us.
   
Copyright 2005 Great Lakes Medical Equipment, Inc.. All rights reserved.