Information Request Form

The Gertie Crib meets all government mandated safety regulations therefore you can purchase the Gertie without a medical prescription.

However, if you have a medical condition which restricts you from properly taking care of baby in a Standard Crib then you may qualify to get this specially designed crib through your health insurance or Third Part Funding. Your information on this Form will help us to figure out how can we help you.

Here you can request information in regards to: Price Quote and/or Third Party Funding

Your zip code will help determine what the price will be. The price quote will include shipping and handling.

The following questions need to be answered to better assist you with determining for third party funding eligibility.

Please select the reason for your disability.

Please give a brief description of disability which requires Gertie Crib

Do you need a wheelchair for mobility?

Please provide the name of the manufacturer and model of the wheelchair.

Expected date of delivery?

Do you see a doctor who is familiar with your medical and physical condition?

Who else in the household will take care of the baby?

Name of your medical insurance company