Request a Refill

*My current supply of diabetic testing supplies are nearly exhausted.  I have less than 14 days on hand.

*I am NOT currently in Nursing Home or Hospital.

*I am requesting a refill of my diabetic testing supplies.

*I only get my testing supplies from Medical Solutions.

*I have been trained on the proper use of these supplies.

Items requested

Diabetic Test Strips
Lancets - Healthy practice to change lancets after EACH test.
Lancing Device - Available every 6 months.
Control Solution - Calibrates meter to ensure accurate results. Expires 90 days from opening.
Meter Batteries - Available every 6 months.

*My typed name below is my signature/authorization to send the items I've checked above and is my written permission to
contact me via phone, email, mail and text.

Name

Date of Birth (MM/DD/YY)

Phone Number (Please include 1+ Area Code when entering phone number)

Email Address

*I understand Medical Solutions will contact me by any means if for any reason this order is not eligible to ship.

*Must be checked for form to be processed. For Medical Solutions purposes in completing your order properly.