Patient Application Forms

This page is for hospital personnel and other medical professionals seeking to qualify a specific patient for equipment from DME Exchange of Dallas.

To download a ZIP archive of all the documents we need completed and faxed or emailed to us, please CLICK HERE.

To download individual forms, please click the appropriate image or text link below. Each file will open as a PDF in a new browser window. Save the document to your local computer. Then, either print and complete the form manually or use any PDF editing software, such as ADOBE’s Acrobat Pro, to complete the form. Finally, either FAX or email the completed form(s) back to us at:


FAX: 888-235-3639

EMAIL: bherseydmeexchange@gmail.com