DME Rental Application NameThis field is for validation purposes and should be left unchanged.Date* Month Day Year CDIB#*Name* First Last Date of Birth* Month Day Year Phone*Email* WK#MessageEquipment Add RemovePlease list one piece of equipment per linePlease note the equipment in need must be related to a health condition. The equipment you request may be new, used, or rented through Health Programs. Once the equipment is no longer needed, it must be returned to the Wichita & Affiliated Tribes Health Programs. Must attach copy of prescription for equipment and must have documentation of health condition.Please check all that apply. Wheelchair Cane Blood pressure cuff Walker Crutches Nebulizer Other Please list:*Signature*Date* Month Day Year Dept of Health – DME Rental EmailThis field is for validation purposes and should be left unchanged.Date* Month Day Year CDIB#*Name* First Last Date of Birth* Month Day Year Phone*Email* WK#MessageEquipment Add RemovePlease list one piece of equipment per linePlease note the equipment in need must be related to a health condition. The equipment you request may be new, used, or rented through Health Programs. Once the equipment is no longer needed, it must be returned to the Wichita & Affiliated Tribes Health Programs. Must attach copy of prescription for equipment and must have documentation of health condition.Please check all that apply. Wheelchair Cane Blood pressure cuff Walker Crutches Nebulizer Other Please list:*Signature*Date* Month Day Year
