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Supportive Bracing Order Form

Select insurance

Tell us about you and your insurance so we can confirm your coverage.

Email

IMPORTANT: Our primary methods of contact are email and texting. Please provide an email address you check regularly.

State you live in

State should match what your insurance has on file.

Primary insurance ID

BCBS MEMBERS - Please include 3 digit alpha prefix

Date of birth

Primary insurance

If you do not see your insurance listed, please contact your insurance for a list of in-network providers.

STOP! You may receive a bill if you have received or ordered supportive bracing, wrist splints, or orthotics through this insurance policy within the past year. By checking this box, I confirm that I have not received or ordered these products through this insurance policy within the past year. I would like to receive email updates from Surgical Shop.

Step 2 of 4

Choose a product type

Select one or more product types. You can combine Wrist Splints and Orthotics – Medi in one order.

Step 3 of 4

Choose a product

Select one or more products, then choose size and color on each card. Use View details for full product info.

Plan confirmed

Step 4 of 4

Contact information

Review your selections below, then complete your contact and insurance details.

Product type —

Product —

Details —

Insurance —

Patient information

First name

As listed on insurance card

Last name

As listed on insurance card

Date of birth

Middle initial

Street address line 2

No PO boxes

Street address

No PO boxes

City

State

ZIP code

Mobile phone

Email

How did you hear about us?

Preferred language

Upload insurance card (front and back)

Your order will be expedited if you upload the front and back of your insurance card.

Upload insurance card (front) Upload insurance card (back) Accepts .jpg, .png, or .pdf

Provider information

Enter your doctor or provider details manually. No provider search is required.

Doctor's first name

Doctor's last name

Practice name

Practice address

Contact phone number

City

State

ZIP code

Fax number

I acknowledge that the provider I entered above is a provider I have seen; otherwise, we may not be able to process my order.

Prescription (optional)

A prescription expedites your order.

Select file

Emergency contact (optional)

First name

Last name

Relationship

Phone number

Special delivery instructions

We do not ask for a signature when shipping packages. If you would like to sign for your delivery, please let us know above.

Promotional code

If the discount code is valid, the discount will be applied when your card is charged.

I understand that if I have dual insurance coverage, I am responsible for payment if only one insurance is listed. I authorize charges to my credit card for any out-of-pocket expenses associated with this order. I have read and agree to the Terms of Sale, Terms of Service, Privacy Policy, and HIPAA Notice. I agree to receive emails from Surgical Shop as described in the Privacy Policy.

After submitting your order, our team will review your insurance coverage and product selection and contact you if additional information is needed.

Request received