Patient Intake

Let's get you set up

Share a few details and our team will verify your insurance, coordinate your prescription, and ship your equipment. Your information is private and secure.

You're requesting Graduated Compression Tights. Feel free to add other products below.

Patient Information

Full name*

Date of birth*

Email*

Phone*

Street address

City

State

ZIP

Insurance Information

Insurance provider*

Member ID*

Group number

Prescription & Physician

If you have a prescription or referring physician, share it here. Don't worry if you don't — we can help coordinate it.

Do you have a prescription?*

Physician name

Physician phone

Products & Notes

Which products do you need?*

List any products you're interested in — e.g. breast pump, compression stockings, recovery kit.

Due date or desired delivery date

Anything else we should know?

I consent to Maternal Relief Co contacting me and using the information provided to verify my insurance benefits and process my equipment order.