Cubby Beds Return Form

1
Full Name* This field is required.
First Name
Last Name
2
Email* This field is required.
example@example.com
3
Phone Number* This field is required.
4
Order Number / PO Number / Serial Number* This field is required.If your order is funded through private pay, waivers, or grants, you can locate your 4-digit order number through your order confirmation email. If your order is funded through Insurance/Medicaid, please reach out to the Durable Medical Equipment Supplier that you are in partnership with to obtain your PO Number. If both are not available, you can look into your Cubby's serial number on the tag of the bed (on the exterior of your Cubby's canopy, below the technology hub).
Please enter one of the following three options listed above.
5
How was your Cubby funded? * This field is required.
Insurance/Medicaid
Private Pay
Charity/Grant
6
Is your Cubby within the 100 days of happiness guarantee?* This field is required.
YES
NO
This begins at the date your Cubby was delivered.
7
Reason for return* This field is required.
8
Did you keep the original boxes for your Cubby order?* This field is required.
YES
NO
Should be Empty: