Catalog Request Form Please fill out the appropriate fields in order for us to understand your needs.

Kanawha Medical offers scooters, wheelchairs, respiratory equipment, incontinent supplies, and more. Just request a catalog to view our full line of medical supplies and products Please fill in the appropriate fields to help us understand your needs.

Required fields are marked with a red asterisk.

Patient Information

Sex:

• Male
• Female

First Name:

Last Name:

Address:

City:

State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zipcode:

Phone Number:

Date of Birth:

Month: 01—Jan  02—Feb  03—Mar  04—Apr  05—May  06—Jun  07—Jul  08—Aug  09—Sep  10—Oct  11—Nov  12—Dec

Day: 01  02  03  04  05  06  07  08  09  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31

Year: 1900  1901  1902  1903  1904  1905  1906  1907  1908  1909  1910  1911  1912  1913  1914  1915  1916  1917  1918  1919  1920  1921  1922  1923  1924  1925  1926  1927  1928  1929  1930  1931  1932  1933  1934  1935  1936  1937  1938  1939  1940  1941  1942  1943  1944  1945  1946  1947  1948  1949  1950  1951  1952  1953  1954  1955  1956  1957  1958  1959  1960  1961  1962  1963  1964  1965  1966  1967  1968  1969  1970  1971  1972  1973  1974  1975  1976  1977  1978  1979  1980  1981  1982  1983  1984  1985  1986  1987  1988  1989  1990  1991  1992  1993  1994  1995  1996  1997  1998  1999  2000  2001  2002  2003  2004  2005  2006  2007  2008  2009  2010

Physician/Insurance Information

Physician Name:

Physician Phone Number:

Other Insurance:

Other Insurance Phone Number:

Applicable Diagnosis and Desired Products

Diabetic:

• Diabetic Shoes
• Gauntlet
• Test Strips
• Syringes
• Lancets
• Alchohol Pads
• Glucometer

Pain:

• Hospital Bed
• Back Brace

CHF:

• Hospital Bed

Stroke:

• Scooter
• Motorized Wheelchair
• Manual Wheelchair

Aspiration:

• Hospital Bed

Medication:

• Hospital Bed

Incontinence:

• Pull-ups
• Wipes
• Diapers
• Underpads
• Bladder Pads
• Moisture Barrier
• Ointment
• Bedside Drain Bag
• Catheters

Limited Mobility:

• Scooter
• Motorized Wheelchair
• Manual Wheelchair
• Walker
• Cane/Crutch
• Rollator
• Bath/Transfer Bench
• Bedside Commode
• Group 1 mattress

Transfer Assist:

• Patient Lift
• Transfer Bath Bench

Pulmonary:

• Hospital Bed
• Nebulizer

Pressure Ulcer:

• Group 1-3 Mattress
• Wound Care dressing
• Surgical dressing

Swallowing Dysfunction:

• Sunction Pump
• Yaunkers

Trach Care:

• Sterile Saline Solution
• Sterile Gauze
• Trach Care Kit
• Suction Catheters

Ostomy:

• Pouch/Wafer
• Paste
• Barrier Wipe
• Deodorizer

Sleep Disorder:

• CPAP
• CPAP Mask

Kanawha Medical TV Commercial

Diabetic Shoes

Click here to check out our TV spot. Quicktime required to view this spot. If you do not have quicktime installed, you can install it here.

Our Equipment

Kanawha Medical provides a full line of durable medical equipment including ambulation aids, supplies for diabetics, respiratory equipment and more. Whether you are reordering supplies or looking for a solution to physical challenges, our staff will listen to your concerns and explain the options available.

Order Assistance

We can help you choose the best equipment and supplies to meet your healthcare needs and we make sure you understand how the products work and explain any safety concerns you may have. One of our trained representatives will be happy to sit down with you and answer all your questions.

In addition to helping you find the right products, we handle all necessary insurance paperwork.

Get a Grip

If you find it more difficult to grasp things because of weakness or pain in your hands, assistive devices can make your life easier. There are a number of products designed to help you accomplish everyday tasks around the house. Jar openers, vegetable peelers and other utensils with larger grip handles, and spring-loaded scissors make it easier to use your hands and maintain independence.