Wound Care Resupply Request

Wound Care Supply Request

Please complete the form below to submit your request for additional Wound Care Supplies.

Rotech Wound Care Complete will contact you within two business days to confirm your request.

Please note: this form is a request for Wound Care Supplies like dressings, collagen dressings, hydrogel, tape, etc. If you are looking for Negative Pressure Wound Therapy Supplies, please go here.

Name(Required)

First Last

Patient ID

Date of Birth(Required)

Preferred Contact Method

Phone(Required)

Enter Email Confirm Email

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Additional Comments

Please do not enter medical information in this field.

EMAIL PRIVACY WARNING: Communications via email over the internet in general, and via unencrypted email in particular, are not secure and there is a possibility that information included in an email can be misdirected or intercepted and read by other parties besides the person to whom it is addressed. You should not use email for emergencies or other time-sensitive matters. By submitting information through our request form, you are consenting to receive communication from Rotech Healthcare Inc. (or any of its subsidiaries) via unencrypted email.

Wound Care Resupply Request

Wound Care Resupply Request

Wound Care Resupply Request

Wound Care Supply Request

Please complete the form below to submit your request for additional Wound Care Supplies.

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