New Customer Information Request
Check your eligibility to receive discreet, monthly deliveries of incontinence and other medical supplies direct to your door through your eligible Medicaid or other insurance plan. Complete this form and PMC will contact you within 1-2 business days for a personal and confidential consultation about what is covered by your plan and which products best fit your needs
1
.
Who will use the incontinence product ?
Adult 18 & Over
Child Under 18
2. Patient / Client Details
First Name *
Last Name *
Date of Birth *
Gender *
Select
Female
Male
Non-binary
Prefer not to say
Other
Street Address *
City *
State *
Select
Armed Forces Americas
Armed Forces Europe: Middle East, & Canada
Alaska
Alabama
Armed Forces Pacific
Arkansas
American Samoa
Arizona
California
Colorado
Connecticut
District of Columbia
Delaware
Florida
Federated States of Micronesia
Georgia
Guam
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Marshall Islands
Michigan
Minnesota
Missouri
Northern Mariana Islands
Mississippi
Montana
North Carolina
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Palau
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Virgin Islands
Vermont
Washington
West Virginia
Wisconsin
Wyoming
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Northwest Territories
Yukon Territory
Zip Code *
3. Contact Information
Primary Email *
Phone *
Preferred Contact
Select
Phone
Email
Text
Who should we contact? *
Patient
Someone else (parent, guardian, spouse, caregiver, etc.)
Primary Contact First Name
Primary Contact Last Name
Contact Phone
Primary Contact Email
Relationship
Select
Parent / Guardian
Spouse
Adult Child
Caregiver
Case Manager
Other
4. Insurance Information
Insurance Type (check all that apply) *
Medicaid
Medicare
Private insurance
Not sure
5.
Supplies You Would Like More Information About
Incontinence or bladder control products
Catheters and urological supplies
Additional supplies
Bathroom equipment
Other
6. Referral Source
How did you hear about PMC? *
Select
Google Search / Search Engine
Social Media
Word of Mouth / Referral
Existing Customer
Online Directory
Referral name or organization
7. Consent and Authorization
By submitting this form, I authorize Professional Medical Corp. (PMC) to contact me using the information provided about this request, insurance verification, account alerts, billing matters, product needs, and order updates. Message frequency may vary. Reply STOP to opt out of text messages. Message and data rates may apply. PMC respects your privacy and uses this information solely for communication related to your request and services.
I agree to be contacted by PMC regarding this request.
Signature
Date