Skip to primary navigation
Skip to content
Skip to footer
ActivStyle
header-right
1.800.651.6223
Pay Bill Online
Careers
Call
Search
Menu
Main navigation
Our Services
Individuals
Caregivers
Healthcare Providers
Case Managers
Managed Care Providers
Our Supplies
Incontinence Supplies
Pediatric Supplies
Urologic & Catheter Supplies
Other Home Medical Supplies
Rely
®
Products
Eligibility
About
Resources
Testimonials
Contact Us
New Customers
Current Customers
Providers/Case Managers
Contact a Sales Rep
Contact Us
New Customer
Name
*
First
Last
Email
*
Phone
*
Address
*
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
How did you hear about us?
*
Search Engine (Google, Yahoo, Etc)
TV Commercial
Friend/Family Member
Healthcare Professional
Other
Insurance Type (check all that apply)
*
Medicaid
Medicare
Other
Not sure
Supplies you would like more information about (check all that apply)
*
Incontinence or Bladder Control Products
Catheters and other Urological Supplies
Ostomy Supplies
Nutritional Supplements
Wound Care Supplies
Other
Questions & Comments
CAPTCHA
*By clicking the SEND button, I consent to receive autodialed and/or artificial/prerecorded voice marketing calls and/or texts from ActivStyle on the phone number provided above. I understand that I will receive these calls or texts even if I am on a federal or state do not call registry. I understand that my consent is not a condition of any purchase.
Current Customer
Name
*
First
Last
Email
Phone
*
Date of Birth
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Address
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Please select one
*
I currently receive supplies from ActivStyle
I have not yet received my first order
How may we help you?
*
I need to reorder my supplies
I'm checking on the status of my order
I have a new address or phone number
Other (please comment below)
Other
CAPTCHA
By clicking the SEND button, I consent to receive autodialed and/or artificial/prerecorded voice marketing calls and/or texts from ActivStyle on the phone number provided above. I understand that I will receive these calls or texts even if I am on a federal or state do not call registry. I understand that my consent is not a condition of any purchase.
