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Diabetes Supplies Order Form

Diabetes care Solution has partnered with Medical Supplies Express to deliver safe, affordable diabetic supplies direactly to your door with free shipping and handling for purchase over $25.

Patient Information

MaleFemale

Medicare

Medicaid

Private

HMO

Not Insured

Products

Item Products Qty Free/Box Total Check To Order
Blood Glucose Monitor $6.97
>Blood Glucose Test Strips $9.97
Single-use Twist Top 100 Lancets 30G $8.97
Control Solutions $9.97
Lancets Device $9.97
Meter Battery
Free Diabetes Start-Up Kit Free
Total Order$

6 Months

12 Months

Life Time

Free Meter

Blood Glucose Monitoring

Physical Activity

Foot Care

Diet Management

With Insuline

With Oral Medication

With Diet & Excersice

Physicians Information

Wavier of Liability /Medical Information Release

I request that my payments or payment of my insurance benefits ( Medicare, Medicaid or Private or HMO) be made to Diabetes Care Solution for any supplies or services furnished to me by Diabetes Care Solution. I understand that I am fully responsible to pay all amounts that are not covered by my insurance .I authorize any holder of medical information about me to release to Diabetes Care Solution any information needed to determine benefits payable for these supplies or services. In addition, I authorize Diabetes Care Solution to release my medical records to insurers as well as medical professionals. I authorize Diabetes Care Solution to contact me by telephone, email or mail regarding my medical supplies.

If patient has signed by making an 'x' due to language barriers or physical limitations, the signature and address of the witness should be entered next to the beneficiary's mark. If the patient is unable to sign due to a physical or mental condition, an Authorized Representative of the patient must complete the section below. By signing on behalf of the customer, you acknowledge that you have authority to do so.

Payment

My check or money order made payable to Diabetes Care Solution is enclosed (do not send cash).

Visa

MasterCard

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Mail Order Form And Payment To