Diabetic Supplies Re-Order Form

1. Enter/Verify the patient's personal information

Name*:
Required

Address*:
Required

Phone Number*:
Required.

Email Address:

2. Are you almost out of diabetic supplies?*
Yes, my testing supplies are almost out (I have 10 days or less of supplies).
No, I have more than 10 days of testing supplies left.

3. Are you authorized to re-order testing supplies?*
I am this patient.
I am a family member, relative, caregiver, or close personal friend of this patient, who is authorized to act on behalf of this patient.

4. Are you using insulin injections?
Yes
No

5. How many times per day are you testing on average?

6. Items to Re-Order (Check all that apply):
Blood Glucose Meter
Test Strips
Lancets
Control Solution
Lancing Device