Order Refill (* Required fields)
Customer Information
First Name: *
Last Name: *
Phone Number: *
Email Address:
State: *
Person completing the information
Same as above
First Name: *
Last Name: *
Phone Number: *
Email Address:
Shipment Information
Please ship my next order on : *
Note: Use the calendar below to select your preferred ship date.
AugustSeptember 2008October
SuMoTuWeThFrSa
31123456
78910111213
14151617181920
21222324252627
2829301234
567891011
 NOTE:
If you are not eligible on the date that you have chosen, you will be contacted by a customer service representative.
1. The brand of strips that I am currently using is
2. Check here to be contacted if you are interested in a NEW, NO CHARGE monitor.
3. Please select below a Full or Partial reorder.
Full reorder. (Includes strips, lancets and control solution)
Partial reorder. I only need the following items:
Test Strips
Lancets
Control Solution (Using control solution will ensure your meter is working properly)
4. In addition to the items listed above, I also need:
A Replacement Battery
A New Lancing Device
Insulin pump supplies (Infusion sets with accessories and cartridges)
5. Has any of your account information changed? (personal, physician or insurance)?
If yes, You will be contacted prior to your shipment date to update your account information.
Is it best to reach you in the morning or afternoon?
© 2007 DIRECT HEALTHCARE SUPPLY I All rights reserved. I Privacy Policy I Contact Us