| Sentry Drug Center #3 (704) 263-0810

Using the RefillRx mobile app? Then you will love our new, ENHANCED Sentry Drug Center mobile app.
Quickly request refills or login and manage your prescriptions on the go!
Available on both iTunes and Google Play.

Call or Visit for All of your Vaccination Needs!

SUPPLIES ORDER FORM

Referral sent from (Location/Name/Phone #)

Date

Patient's First Name

Patient's Last Name

Male/Female

Birth Date (XX/XX/XXXX)

Address

City / State

Zip Code

Patient Phone #

Facility

Discharge Date

Physician Information

Physician

NPI#

Phone Number

Fax Number

Address

City / State

Zip Code

Primary Diagnosis

Secondary Diagnosis

ICD-10 Code

Insurance Information

Primary Insurance

Insurance Phone Number

Policy ID #

Group #

Insured Relationship to Patient

Insured Name

Birth Date (XX/XX/XXXX)

Secondary Insurance

Insurance Phone Number

Policy ID #

Group #

Insured Relationship to Patient

Insured Name

Birth Date (XX/XX/XXXX)

Incontinence Supplies Order

Tape Side Briefs

Pull Ups

Quantity

SIZE:

Small

Medium

Large

2XL

Underpads (Chux)

Quantity

Other - Gloves, Catheters, Ostomy, Nutritionals

Type / Size / Qty

NORTH CAROLINA MEDICAID REQUIRES A PRESCRIPTION FROM A PHYSICIAN IN ORDER TO OBTAIN INCONTIENCE SUPPLIES VIA MEDICAID. MEDICAID LIMITS BRIEFS TO 192 PER MONTH, PULL-UPS TO 200 PER MONTH, AND UNDERPADS TO 150 PADS PER MONTH.

Using the RefillRx mobile app? Then you will love our new, ENHANCED Sentry Drug Center mobile app. Quickly request refills or login and manage your prescriptions on the go! Available on both iTunes and Google Play. Call or Visit for All of your Vaccination Needs!

SUPPLIES ORDER FORM

Physician Information

Insurance Information

Incontinence Supplies Order

SIZE:

Using the RefillRx mobile app? Then you will love our new, ENHANCED Sentry Drug Center mobile app.
Quickly request refills or login and manage your prescriptions on the go!
Available on both iTunes and Google Play.

Call or Visit for All of your Vaccination Needs!