Forms

FHS Refill Request

Request recurring medical supply refills directly through FHS.

FHS New Patient Form

Share patient, referrer, clinic, and insurance details to start services with FHS.

FHS Get My Products

Tell FHS which supplies you need so the team can review product options and next steps.

FHS Diabetic Supplies Order Form

Collect patient, clinic, and diabetic supply details for FHS diabetic supply orders.

FHS Gestational Diabetic Form

Collect gestational diabetic patient, supply, and referring source details for FHS intake.

FHS Family Clinic Form

Collect clinic, patient, insurance, and supply details for family clinic intake through FHS.

FHS New Pediatric Patient Form

Collect pediatric patient intake details for referral, clinic, supplies, nutrition, catheter needs, and consent.

FHS Urological Prescription Form

Collect catheter, patient, clinic, and referring source details for FHS urological prescription intake.

FHS Enteral Nutrition Order Form

Submit patient, facility, and product details for enteral nutrition orders through FHS.

Waiver Referral Form

Submit a waiver referral for specialized medical supplies with patient, provider, and product details.

FHS Referral Form

Send a standard FHS referral with referrer, clinic, patient, and requested product information.

FHS Consent Form

Authorize FHS to discuss care and coordinate medical supply services with approved contacts.

FHS Change of Supplier Form

Request a switch to FHS as your medical supply provider and submit the required consent.

FHS Follow Up

Complete a follow-up about your current supplies, usage, and any changes since your last order.