Quantcast
0



Re-Ordering from Discount Diabetic is this easy:

  • Complete and submit the form below. Required fields are noted with an asterisk (*)
  • Update Your Information Click Here!

* Please fill in required fields

First Name Last Name
Address 1 Address 2
City State
Zip Phone
Alternate Phone Email
Patient ID#:
Comment:
   
I acknowledge receiving the last shipment. *
I request you renew my Physician's Order for the supplies.*
I will be nearly exhausted of my supplies, 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 *
Number of Times You Test Your Blood? *
   
Supplies Needed :
Test Strips
Lancets
Lancing Device
Control Solution
Batteries
If your Information has Changed Click Here to Update it.
 
Personal Information

First Name Last Name
Address 1 Address 2
City State
Zip Phone
Alternate Phone Email

Doctor Information

Doctor Name:
Doctor Phone #:

Insurance Information

Primary Insurance:
Group #:
ID #:

Secondary Insurance:
Group #:
ID #:

Discount Diabetic supplies all the top quality brand name diabetic products from the leading manufacturers.

For more information about any of these supplies, please call us toll free at
1 (800) 714-0490.

Ask about our line of Glucose Meters.

Why Discount Diabetic?

  • No hassles!
  • Medicare certified.
  • We do ALL the paperwork.
  • Convenient delivery to your door.
  • Professional, personal service.
  • Order safe and secure by phone at
    1 (800) 714-0490.
Discount Diabetic has earned The Joint Commission’s Gold Seal of Approval™

Copyright © 2006 Discount Diabetic | All Rights Reserved
W3C XHTML 1.0 | Privacy Policy