Name:________________________________________________________________________________
(First) (Middle) (Last)

Address:______________________________________________________________________________

City:_________________________ State:_____________ Zip Code:____________________

Home Phone #:____________________________ Other Phone #:_____________________
Sales Representative will call

Social Security #:______________ Date of Birth:___/___/___ Sex:____ Marital Status:__

Medicare #:____________________________ Part B Effective Date:____________________

Name of Secondary Insurance:_________________________________________________________

Insurance Phone #:_______________ Policy or ID #:______________ Group#:_________

Name of Policy Holder (If not patient):__________________________Date of Birth:______

Policy Holder’s SS #:______________________ Employer’s Name:____________________

City:___________________ State:_____ Zip Code:________Phone #:_________________

Physician’s Name:__________________________________ UPIN #:__________________

Address:________________________________________________________________________________

City:_____________________________ State:_________Zip Code:___________

Telephone No. _______________ Fax. No._________________ Date of Last Visit:________

Are you currently using insulin ? ____________________________________ Yes ? No ?

How many times do you test your blood glucose levels each day ?________________

What brand of blood glucose meter do you own?_______________________________

Did Medicare cover your present glucose meter?______________________ Yes ? No ?

Are you interested in a new meter?__________________________________ Yes ? No ?

• Home Medical Supplies, Inc. • 2260 S. Xanadu Way, Suite 335
• Tel. (866) 867-3638 • Fax. (303) 705-1957