VitalCare Home Health Care and Medical Equipment

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The Easy Way

To Get Your

Diabetic Supplies!

VitalCare can ship your diabetic testing supplies right to your home and save you the time and expense of driving to the store.

Just fill out this Patient Information form and submit it, and one of our friendly staff will call you to confirm your order.

VitalCare can bill most Medicare, Medicaid, and Blue Cross claims on your behalf.

If you have questions about diabetic testing supplies, please contact our Call Center at 800-342-7711, Mon-Fri, 8:30am-5pm EST.

VitalCare's Mission
"Home Healthcare That
You Value and Trust"

Diabetic Supply Order Form

Patient Information

*All Fields are Required

Patient Status Questionnaire

In order to better serve your needs for this reorder, and in the future, please answer all of the following.

Current Diagnosis:

Survey:
Has your Insurance changed?	Yes No
Have you changed Physicians?	Yes No
Name of current Doctor?
Are you Insulin dependent?	Yes No
Has your Times Testing changed?	Yes No
Number of Times Tested per day?

Diabetes Supplies Reorder

Qty	Product #	Description
	185011	One Touch Test Strips, Box of 50
	185021	One Touch Ultra Strips, Box of 50
	185031	Sure Step Strips, Box of 50
	185402	UltraFine Lancets, Box of 100
	185405	Monolet Lancets, Box of 200
	185040	Monitor, One Touch Ultra, each
	185015	Control Solution, One Touch
	185042	Control Solution, One Touch Ultra
	185412	Lancet Device