Shipping address if different form above(Your shipping address must be a deliverable U.S Post Office street address):
Social Service Organization
You must the form before we can send your mediciness.I attest that information provided in this application is complete and accurate.This authorization or a copy shall be valid for 12 months form the date of signature.I understand that Diabetes Care Solution reserves the right to request income verification form me or refuse my application based on any
misuse, abuse or illegal distribution of any products in this program. I will not seek reimbursement of any feel Ipay to Diabetes Care Solution form my health insurance, including Medicaid, Medicare or similar programs.
Event Code: 788
If Placing An Order
How to pay:Check or money order payable to Diabetes Care Solution, Or credit Card.Please do not send cash.
I authorize Diabetes Care Solution to charge this credit card for payment on my fist order.