Family of Companies – Zoellner Medical Group

Our Family of Companies

Serving Patients Across Oklahoma

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Patient Information

Full Name *

Phone Number *

Email *

Date of Birth *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Medical Equipment Required *

CPAP (Static Pressure)
APAP (Auto CPAP)
BI-LEVEL (BiPAP/VPAP)
BI-LEVEL AUTO (BiPAP/VPAP)
BI-LEVEL W/ Back Up Rate
Home Oxygen

Physician's Name *

Physician's Phone Number *

A to Z Madison Medical

Committed to providing superior home medical products. Our company stays on the cutting edge of technology, knowing that our customers are getting the best options available at an affordable price. We pride ourselves with having exceptional customer service with 20 plus years of experience. Our approach is creating personal relationships with our customers and helping them gain back a normal life.

Diagnosis *

Obstructive Sleep Apnea
Central Sleep Apnea
Complex Sleep Apnea

Questions Before Scheduling *

Do you take any medications?
Any Disabilities or special needs we need to be aware of?
Do you use a walker, cane, or wheelchair?
Are you Able to get in and out of bed and to and from the restroom on your own?
Do you currently have a CPAP?
Do you use a CPAP every night?
Do you have pacemaker?

Comment or Message *