Reorder Supplies


Please provide us with the following information. One of our patient advocates will call you to confirm everything and answer any questions you may have. If you’d prefer to reorder by calling us directly, please reach us at (888) 507-5539 or (561) 795-1636.

First Name*
Middle Initial
Last Name*
Date of Birth (MM/DD/YYYY)*

 
Shipping Address (Leave these fields blank if there hasn't been a change)

Address 1
Address 2
City
State
Zip

Patient Primary Phone*
Patient Alternate Phone
Patient Email Address*

 
Diabetic Reorder

Reorder Diabetic Supplies?*
 Yes    No
Times Testing*
Syringes, Pentips, Pump?*
Diabetic Medication*
Strips Remaining*

 
Respiratory Reorder

Reorder Respiratory Supplies?*
 Yes    No
Nebulizer Frequency*
Nebulizer Medication*
Vials Remaining*

 
Insurance Information (Leave these fields blank if there hasn't been a change)

Primary Insurance
Phone
Insurance ID
BIN
PCN
Group

Secondary Insurance
Phone
Insurance ID
BIN
PCN
Group

Pharmacy Insurance
Phone
Insurance ID
BIN
PCN
Group

Comments (Updated address, temporary address, etc.)

All fields with a red asterisk* are required. If not applicable, please write "N/A".


 

By submitting, I give express written consent authorizing Prescriptions Plus, Inc. to contact me by telephone (including calls from an automated telephone dialing system) and/or email in regards to my medications and medical supplies. If completed entirely, I agree to have my doctor contacted directly. I understand that I am not required to provide my consent as a condition of purchasing any products or services and this offer does not qualify me for any prize or reward.
*Co-pays and deductibles may apply.