US Med | Diabetic Reorder

Name: First/Last *

Evening Phone *

Email *

Patient ID#

How many times per day on average
are you actually testing your blood:

Are you using Insulin Injections?

Comments

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.

I Need more:

Test Strips (*)

Lancets

Free Gift

* Please make sure all required* boxes are checked before submitting the form

United States Medical Supply • 8260 NW 27th Street, #401 • Miami, FL 33122

call us 1-800-7-USMED-1

UNITED STATES MEDICAL SUPPLY

Diabetic Supplies Re-Order Form