Patient Reorder Form

Please complete the following:

Brand & Model of Testing Meter:
            (for example:  One Touch Ultra or Ascensia Elite XL, etc)

Testing Frequency:  time(s) per day

Please check the items you are requesting:

Testing Strips

Lancets

Batteries for Meter

New Lancing Device

New Meter : if yes, please state preferred Model

Vacuum Erection Therapy System

(The items below are not covered by Medicare.  If you are insured by Medicare and wish to purchase, please contact us at 800-933-8085 to order.)

INSULIN:

 Brand   Units taken per day   

 Brand   Units taken per day   

 Brand   Units taken per day   

SYRINGES:
            Size (cc/gauge)   Quantity Boxes of 100
            Size (cc/gauge)   Quantity Boxes of 100
            Size (cc/gauge)   Quantity Boxes of 100

ALCOHOL SWABS:    Quantity Boxes of 100

Enter your comments in the space provided below:

Contact Information:

Name *
Email *
Phone *
Fax

Click on "Submit" and wait for the Confirmation Page to appear.
* indicates a required field