Physicians Center

American Medical Sales & Repair is committed to helping our customers breathe easier. This includes a positive buying experience. In order to make sure that we are providing equipment that meets the oxygen requirements you are prescribing, we are required to retain a prescription for any oxygen concentrator we sell. We are able to take prescriptions via fax, e-mail (scan) or you can fill out our on line prescription form. When using our on-line form, we will send you a courtesy copy of the prescription at your return e-mail address.

Physician Information (All fields are required.)

Referring Professional's Name

Primary Contact

Fax Number

Physician Name

Phone Number

NPI Number

Patient Information (All fields are required.)

Name

City

Zip

Sex

Address

State

Phone

Date of Birth

Primary Diagnosis

COPD Chronic Bronchitis Emphysema Asthma

Other:

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