Re-Ordering from Discount Diabetic is easy:

• Complete and submit the form below. Required fields are noted with an asterisk (*)
• To update your personal information, doctor information or insurance information Click Here!

*Please fill in required fields
*First Name:
*Last Name:
Address 1:
Address 2:
City:
State:	Select a state Alaska Alabama Arkansas Arizona California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming Puerto Rico Guam Virgin Islands America Somosa
Zip code:
*Phone Number:	(e.g. ###-###-####)
Alternate Phone Number:	(e.g. ###-###-####)
*Email:
Patient ID #:
Comment:
	I acknowledge receiving the last shipment.*
	I request you renew my Physician's Order for the supplies.*
	I will have less than 10 days worth of diabetic testing supplies by the delivery date, and require and request that you send my next shipment of supplies when due again.*
	I understand I can only receive supplies from one provider at a time and that provider is Discount Diabetic. I have not received supplies in the past 3 months from another company.*
Select One Less than 1/day 1/day 2/day 3/day 4/day 5/day 6/day	Number of times you test your blood?*
Supplies Needed
	Test Strips
	Lancets
	Lancing Device
	Control Solution
	Batteries
If you had a paper document, you would confirm that you agree by signing your name. In this instance, you can confirm that you agree by clicking the box below. If you click the box below, it is the same as if you were signing a piece of paper. If you intend to sign this reorder form, please click the box below.

* Please fill in required fields

Personal Information
*First Name:
*Last Name:
Address 1:
Address 2:
City:
State:	Select a state Alaska Alabama Arkansas Arizona California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming Puerto Rico Guam Virgin Islands America Somosa
Zip code:
*Phone Number:	(e.g. ###-###-####)
Alternate Phone Number:	(e.g. ###-###-####)
*Email:
Doctor Information
Doctor Name:
Doctor Phone #:
Insurance Information
Primary Insurance:
Group #:
ID #:
Secondary Insurance:
Group #:
ID #: