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Reorder Your Diabetes Supplies - Simply & Securely

Reordering your diabetes supplies is simple through our diabetes resupply form. Just provide us with some basic information about yourself, when you'd like to pick up your order, what you need reordered and any other notes. After that, we'll get your order ready. If you have any questions about diabetes or diabetes supplies - contact us.

  • Contact Information

  • Are you our patient placing an order for yourself?

    Are you our patient placing an order for yourself?*

  • If a DMS representative needs to reach out to you regarding your order how do you prefer us to contact you?

    If a DMS representative needs to reach out to you regarding your order how do you prefer us to contact you?*

  • Physician's Information

    Please provide information for the doctor who treats your diabetes.

  • Insurance Information

  • Was there an Insurance Change?

    Was there an Insurance Change?*

  • Please select the supplies that you would like to have refilled:

  • Please select the supplies that you would like to have refilled:
  • Please select the supplies that you would like to have refilled:
  • Would you like to receive the same supplies you received on your last order?

    Would you like to receive the same supplies you received on your last order?*

  • Have you incorporated am insulin pump into your diabetes self-management?

    Have you incorporated an insulin pump into your diabetes self-management?*

  • If in Southeast Louisiana, would you be interested in any additional services DMS offers?

    If in Southeast Louisiana, would you be interested in any additional services DMS offers?

  • 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.

    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.*

  • If a coinsurance payment is required by my insurance, I authorize Diabetes Management & Supplies to charge my credit card on file up to the following amount

    If a coinsurance payment is required by my insurance, I authorize Diabetes Management & Supplies to charge my credit card on file up to the following amount*


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