First Name:

Last Name:

Email: (Example:

Phone Number: (XXX-XXX-XXXX)

(Please use the number we have on file for you)

Account Number: (optional)

Items to reorder:

CGM Sensors
CGM Transmitter
Test Strips
Control Solution
Lancing Device

If any items such as address, doctor, or insurance have changed, please tell us what has changed and 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.