Reorder

First Name:

Last Name:

Phone Number:

E-mail Address:

Account Number (optional):

Are you using insulin injections?

Yes No

How many times a day are you testing on average?

Select Less than 1 time per day 1 time per day 2 times per day 3 times per day 4 times per day 5 times per day 6 times per day

Are you almost out of diabetes testing supplies?

My testing supplies are almost out (I have 30 days or less of supplies)
I have more than 30 days of testing supplies left.

Items to reorder:

Test Strips
Lancets
Control Solution
Lancing Device (if eligible)

Has any of your information changed? Please list changes such as address, doctor, insurance, and list the new information below:

I acknowledge receiving my last shipment. I am nearly exhausted of my supplies, and require that you send my next shipment of supplies when due. I am trained and capable of using the supplies to manage my blood sugar. I acknowledge receiving the supplier standards, warranty info and training materials. I authorize the company to renew my prescription, to verify my insurance benefits, to contact me, to request and accept the release of my relevant medical records, and to submit claims and claim assignment of payments of medical benefits for items/services provided to me.