Reorder Form

Required fields **


Your next refill order can be changed by clicking on it or left as is to ship on
 
Please select the option that applies:
 
Send All Items Received on My Last Order (if I'm eligible)**
 

(Please list any other items you may need)

Other items needed:

 
Or
 
 
I only need the following items: (check all that apply)**
 
Test Strips
Lancets
Control Solution
Lancing Device
(eligible every 6 months)

Infusion sets
Cartridges/Reservoirs
IV Preps/Barrier
New Insulin Pump
(may be eligible every 5 years)

(Please list any other items you may need)

Other items needed:


Please answer all questions: Questions 2 & 3 are a Medicare requirement for coverage of pump supplies.

1. Do you have Medicare?** Yes No
 
2. When was your last doctors visit for your diabetes?**

3. When is your next doctors visit for your diabetes?**

4. What is the name of the test strips that you are using?

5. How often are you testing your blood sugar glucose each day?**

6. What is your shipping address for this order?

Address 1**

Address 2

City**


State**


Zip Code**



7. What is your primary insurance? **

8. What is your secondary insurance?

Do you have any family/friends that may benefit from our services? Yes No


Please enter your first name:**

Please enter your last name:**

Please enter your email address: **    

Date:




Thank you for your order.

Please click only once on Place Order or your order may be duplicated.