UNITED STATES MEDICAL SUPPLY

Better Service, Better Care
Call us at 1.800.787.6331
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Online Referral Form

Feel free to print and copy the Fast Start form and fax to us at 1-800-747-9060, or you may complete the Online Referral Form below.

Upon receipt of this form, United States Medical Supply will:

  1. verify insurance coverage,
  2. call and confirm needs with the patient,
  3. express ship the requested medical supplies to the patient.

We will then provide your patient their supplies as needed per your orders with free shipping.

CONTACT INFORMATION
Name of Person Completing Form:*  
Phone:*    


Would you like a new or replacement FastStart Diabetic Meter Kit for your next diabetic patient for FREE? (includes a FREE Meter, Test Strips, Lancets, Lancing Device, and educational material to help your patient start managing their diabetes)
PATIENT INFORMATION
Name*   Phone*    
Address*   DOB(MM/DD/YYYY)*  
City*   Sex*
State* Zip*   Language*
INSURANCE
Primary Company*   Secondary Company*  
Policy #*   Policy #*  
Phone*     Phone*    
DIABETIC SUPPLIES*
Using Insulin Injections?
# Times Testing Per Day  
Meter Type Currently Using  

We will send patient a new meter for FREE!

RESPIRATORY SUPPLIES*

Medications Administered through Nebulizer:*



 		# Times/Day:  
NEW CPAP MASK & TUBING*
Current Mask Using:
Sleep Doctor or Sleep Study Location Phone:
PHYSICIAN INFORMATION
Name*   Phone*    
Address*   Fax
City*   NPI*  
State*   Zip*  
 
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United States Medical Supply • 8260 NW 27th Street, #401 • Miami, FL 33122

call us 1-800-7-USMED-1