SERVING PATIENTS NATIONWIDE EASY REORDER "*" indicates required fields Step 1 of 3 33% Reorder AuthorizationI acknowledge receiving my last shipment. I am nearly exhausted of my supplies and have less than a 14 day supply on hand. I require that you send my next shipment of supplies when due. I authorize the company to renew my physician's order, 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.Patient First Name* Patient Last Name* Caregiver Name (if you are the patient, type N/A)* Date of Birth Phone*Email* Ship-To Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Is your ship-to address the same as your mailing address? Yes No What is your mailing address? Street Address Address Line 2 City State / Province / Region ZIP / Postal Code ProductsPlease select the category of products you are authorizing us to ship.products Incontinence (Diapers, Pull-Ups, etc.) Diabetes Testing Supplies Catheters/Urological Supplies Thickeners (Simply Thick, Thick It, etc.) Oral Nutrition (Boost, Ensure, etc.) CGM Supplies How many days are left on your current sensor?* Do you have any unused sensors on hand?* Yes No How many unused sensors do you currently have?* Do you need any additional supplies with your sensors?* Yes No What additional supplies would you like to order?* Would you like to duplicate last month's order?* Yes No Change My OrderIf you would like to make a change to your order, please let us know below. If you have any questions and would like to speak with a representative (not an automated system), please feel free to call our office at (877) 670-1120.order change
