Submit Form

Please submit the following information if you would like to determine what supplies are covered by insurance or what great cash prices we can offer.  Contact us - we can help you lower or eliminate your diabetic supplies costs.  All information is kept strictly confidential.  Please see our Privacy Policy for more information.

	**Required Fields
**First Name:
**Last Name:
Phone:
**Email:
Diabetic Testing Needs:	1 time/day 2 times/day 3 times/day 4 times/day 5 times/day other
Choose the supplies that you are requesting:
Glucometer:
Test Strips:
Syringes:
Lancing Dev:
Lancets:
Other:
If you chose "Other", please explain:
Choose your preferred payment method:
Private Insurance:
Medicare:
Medicaid:
Cash:
Credit Card:
Other:
If you would like us to verify coverage/eligibility before we contact you, please provide the following:                                  (if you have secondary, you may re-enter and re-submit)
Insurance plan Name:
Insurance Number/ID:
Insurance Ph. Number (from back of card)
Date of Birth:
General comments or questions:
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