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YOUR INFORMATION


Select Physician:



Where to Send Prescription: Pharmacy Number:


Your Full Name:


Your Date of Birth:

Social Security Number (Last Four Digits Only):

Address:

City, State, Zip:

Home/Cell Phone:

E-Mail:

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MEDICATION INFORMATION

Name of Medication:


Dosage:



Number of Pills:



Number of Days Supply:



Number of Refills:


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INSULIN


Type:


Units Per Day:


Type:



Units Per Day:


Type:



Units Per Day:


Pens or Vials:

  

  

  


No. of Days Supply:


Number of Refills:


No. of Days Supply:



Number of Refills:


No. of Days Supply:


Number of Refills:



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GLUCOSE TESTING SUPPLIES




Medicare Guidelines

1 test strip per day if oral treated diabetic

3 test strips per day if insulin treated diabetic


Type:


Units Per Day:


Type:



Units Per Day:


Type:


Units Per Day:


Brand of Test Strips:




Number of Test Strips/Day:




Number of Days Supply:





Lancets Requested:

 
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