Hospice Orders

Kohll's Rx is proud to support Hospice Equipment Orders for facilities throughout the Omaha, Lincoln, and Southeast Iowa areas.

Please enter your location code to access your facility's order form.

Comments

This field is for validation purposes and should be left unchanged.

Name

First Last

Facility Code(Required)

Enter Your Email Address(Required)

Request Type(Required)

Incoming Client Advisory

Place Hospice Equipment Order

Place Notification of Medication Order

Notification of Patient Death

Incoming Client Information(Required)

Please provide the general information for this client's needs, including the incoming date with equipment delivery date and time.

Incoming Client Location(Required)

Please provide the hospice facility's name and general location. (Iowa, Omaha, Lincoln, etc)

Patient Name(Required)

First Last

Date of Birth(Required)

Date of Death(Required)