Are you testing according to your prescriber’s orders? Are you testing according to your prescriber’s orders? Yes No

Your insurance records show that you are eligible to receive new diabetic supplies, if you need them. Your insurance carrier requests we document the number of supplies you have on hand. Do you have less than a 2 week supply of your normal diabetic supplies and would you like to order new supplies? Your insurance records show that you are eligible to receive new diabetic supplies, if you need them. Your insurance carrier requests we document the number of supplies you have on hand. Do you have less than a 2 week supply of your normal diabetic supplies and would you like to order new supplies? Yes No

Have you changed to a new brand or model of meter since your last order? Have you changed to a new brand or model of meter since your last order? Yes No

Have there been any changes to your insurance, doctor, doctor's orders, or your address since the last time we contacted you? Have there been any changes to your insurance, doctor, doctor's orders, or your address since the last time we contacted you? Yes No