Please complete the following contact information:

First Name:	*
Last Name:	*
Organization:
Street Address:	*
Address (cont.):
City:	*
State/Province:	*
Zip/Postal Code:	*
E-mail:	*
Re-enter E-mail:	*

How would you rate your overall experience at Medical Home Care?

Additional Comments:

Did you know we offer free delivery to surrounding area's and ship using UPS?

Yes        No

Did you know that you can now order your monthly supplies online, and have them

delivered to your residence without calling?

Yes        No

Please feel free to offer us any comments or suggestions below:

Thank you for your participation! Your 10% off coupon will be mailed within two business days and can be used towards any purchase or equipment rental under $300.00!

(Not acceptable for wheelchair accessible van rentals)