Get monthly delivery of your medical supplies from ActivStyle.
Receiving your medical supplies is easier than ever! Let us do the hard work:
  • We contact your doctor for a prescription
  • We process the insurance forms
  • We remind you when it is time to reorder, so you never run out

Please complete this three-part form to see if you are eligible to receive medical supplies at little to no cost through insurance. The form asks for 1. Patient Information, 2. Medical & Insurance Information, and 3. Supplies Needed. Only the fields marked with an * are required; but the more information you provide the faster and better we will be able to help you. Completing all three parts of this online form is not required, but you must click the SUBMIT button on the last page in order for us to contact you.

1. Patient Information
* These fields are required
*Patient Name
*Date of Birth
*Patient Phone Number
*Email Address
*How did you hear about us?
*Street Address
Street Address 2
*Zip Code
Primary Contact Information
Primary Contact’s Name
Primary Contact’s Phone Number
Primary Contact’s Email Address