Diabetes.am - Patient Reorder Form

Patient Reorder Form

For current patients only, please. For new patients, please first complete the Patient Application first - thank you!
We understand that testing needs change, and you may need additional supplies prior to your scheduled quarterly shipment. Please feel free to let us know what items you are needing via this form.
*Fields marked with are mandatory**
Supplies Requesting

Glucometer brand		Quantity
Glucometer batteries		Quantity
Testing strips		Quantity boxes of 50
Lancets		Quantity boxes of 100
Lancing device		Quantity
Control solution		Quantity; vials
Erection pump		Quantity
(The items below are not covered by Medicare. If you are insured by Medicare and wish to purchase, please contact us at 1 (702) 649 5600 to order.)
Alcohol swabs		Quantity boxes of 100
Insulin		Quantity; vials
Insulin		Quantity; vials
Insulin		Quantity; vials
Syringes		Quantity boxes of 100
Syringes		Quantity boxes of 100
Syringes		Quantity boxes of 100
Enter your comments in the space provided below :


Contact Information

Name *
E-mail *
Phone *
Fax
Please contact me as soon as possible regarding this matter.

Click on "Submit" and wait for the Confirmation Page to appear.