Horizon Healthcare Services

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Please complete the form below to receive price quotes for Enteral Feeding & Supplies.
Items marked with an ( * ) are required fields.

Disclosure: This is not a secured site, information you provide on this form can not be guaranteed to be confidential on the internet.

*Name:
*E-mail:
Phone:
*Date Needed:

1.		Name of enteral product inquiring about?

2.		Amount per day, as prescribed by physician:

3.		Are you drinking this product or using it through a peg tube?
		Drinking Peg Tube
		--- If you answered "peg tube", continue to question 4.--- --- If you answered "drinking", continue with question 6.---
4.		How is your physician ordering your enteral feeding? (Example: 100ML per hour for 12 hours daily)

5.		How is the feeding being fed?
		Pump Gravity Syringe
6.		Would you like pricing on supplies in addition to the enteral feeding?
		Yes No
7.		What is your primary insurance?

		Policy #: Group #: Employer: Subscriber (if different than patient) :
8.		What is your secondary insurance ?

		Policy #: Group #: Employer: Subscriber (if different that patient):
9.		How would you pay for this? (We accept Visa, Mastercard and Discover)
		Cash Check Money Order Credit Card
		Disclosure: This is not a secured site, information you provide on this form can not be guaranteed to be confidential on the internet

		Number to call for information 800-848-3204 or 717-290-3590; Email: tnhiggin@lha.org