Join Us in Just a Few Simple Steps

We’ve streamlined our process to make it as effortless as possible for you.
We handle all coordination with your doctor and insurance provider, taking care of the required paperwork and verifying your insurance benefits. Our hassle-free approach ensures your supplies are delivered promptly—without any extra steps or effort on your part.

Please fill out the form below to become a patient and start the process of receiving your new supplies!

Patient Name

First Name

Last Name

Patient's Phone #

(###)

###

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Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Insurance Provider

Doctor's Name

First Name

Last Name

Doctor's Phone

(###)

###

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Consent to Contact

By checking the yes box, you give permission for Lincoln Medical Supply, Inc. to contact you regarding our products or services via phone, email, or sms message, including automated technology, to the information you have provided. This consent is not required to receive supplies and you can inform us to stop communications at any time. Enter your full name as a Signature.

Checkbox

Consent to Contact

Yes