First Name:

Please enter your first name

Last Name:

Please enter your last name

Date of birth:

Please enter a valid date of birth Invalid Date format. Valid Date Format mm/dd/yyyy

Email: (Example: name@emailbox.com)

Please enter your valid email address Invalid Email Format

Phone Number: (XXX-XXX-XXXX)

Please enter a valid phone no. Invalid Phone Number Format

(Please use the number we have on file for you)

Account Number: (optional)

Are you using insulin injections?

Yes

No

On average, how many times per day do you test your blood sugar levels?

Select Less than 1/day 1/day 2/day 3/day 4/day 5/day 6/day

Please estimate how many days of supplies you have remaining and select from below.

0 (no strips left) 1 day 2 days 3 days 4 days 5 days 6 days 7 days 8 days 9 days 10 days 11 days 12 days 13 days 14 days 15 days 16 days 17 days 18 days 19 days 20 days 21 days 22 days 23 days 24 days 25 or more days

Items to reorder:

	Test Strips
	Lancets
	Control Solution
	Lancing Device (if eligible)

To update your account information, please click here: https://www.usmed.com/current-patients/change/

You have to agree to our terms before you can reorder. I acknowledge receiving my last shipment. I am nearly exhausted of my supplies, and require that you send my next shipment of supplies when due. I am trained and capable of using the supplies to manage my blood sugar. I acknowledge receiving the supplier standards, warranty info and training materials. I authorize the company to renew my prescription, to verify my insurance benefits, to contact me, to request and accept the release of my relevant medical records, and to submit claims and claim assignment of payments of medical benefits for items/services provided to me.

Sorry, we couldn't process your order at this time, please call us at 1-866-723-6958 to place your order.