RE-ORDER SUPPLIES

The Diabetes Store offers existing patients the opportunity to re-order your testing supplies online. Your Diabetes Store account number is usually two-three alpha characters followed by four numeric characters, but it is alright if you don't have it.

It is very important that you comment on any changes (doctor, address, meter, etc) in the comment section. If you would like to speak to one of our customer service representatives about your order please call (901)312-3150 or (800)501-1556. Please be sure to complete our online Diabetes Store Survey.

The Diabetes Store Re-Order Form

Please enter the patient's information.

Name: *

Address:

Phone Number: *

Diabetes Store Account Number (if known):

Email Address:

Are you almost out of diabetes testing supplies?	Yes, I have less than 14 days of testing supplies remaining. No, I have more than 14 days of testing supplies remaining.

Are you authorized to re-order testing supplies for this patient?	I am this patient. I am a relative, caregiver, or close personal friend of this patient, who is authorized to act on behalf of this patient.

How many times per day is this patient testing?:

Diabetes supplies requested for re-order? (Unselect any that do not apply)	Blood Glucose Monitor /Meter Battery for Meter Test Strips Lancets Control Solution Lancing Device (Medicare will pay for two per year or one every six months)

Comments: