Hampton Homecare

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Appointment Request Form

Complete all required fields so we can schedule your appointment. It takes about five minutes.

After you submit, a confirmation page will appear. Need help? Call 1-866-229-5418 and we can complete this with you.

1Consent

You are receiving this communication because your doctor prescribed sleep equipment and supplies for you. Please complete the requested information and select a preferred and alternate appointment date and time slot. We will make every effort to accommodate your primary selection. An appointment notification will be sent; if you need to cancel or change your appointment, contact [email protected] or use live chat at hamptonhomecare.com/contact-us.

By providing your phone number and checking this box, you agree to receive SMS appointment scheduling and reminders, order and delivery updates, equipment resupply notifications, troubleshooting and support follow-ups, and patient satisfaction surveys from Hampton Homecare. Message frequency may vary. Standard message and data rates may apply. Reply STOP to opt out. Reply HELP for help. Consent is not a condition of purchase. Your mobile information will not be sold or shared with third parties for promotional or marketing purposes. See our SMS Terms and Privacy Policy.

Yes, I consent *

2Personal information

First name *

Last name *

Email *

Phone number *

Date of birth *

Gender *

3Address

Street address line 1 *

Street address line 2

City *

State *

ZIP code *

4Emergency contact

Full name *

Relationship *

Phone number *

5Insurance and financial responsibility

Responsible party *

Patient

Guardian

Do you have insurance? *

Yes

No

Insurance provider name

Insurance member name

Insurance member ID number

Insurance provider phone number

Insurance claims address

Front of insurance card

Back of insurance card

Photos are attached to your request; a clear picture of each side helps us verify coverage faster.

6Preferred appointment dates

Preferred date option 1

Morning

Afternoon

Preferred date option 2

Morning

Afternoon

7Agreement and signature

View our patient policies (PDF)

Patient 13 or older. For minors this consent only applies to reproductive and substance abuse services. Minor patients will be counseled about the importance of discussing health care concerns with a parent or other trusted adult.

I agree to the policies *

Type your full name to sign *

8Security check

Need help? Call 1-866-229-5418.

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