CUSTOMER INFORMATION WORKSHEET


PLEASE PRINT THESE SHEETS, FILL THEM OUT, AND FAX TO 303-705-1957

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

ugg italia duvetica piumini peuterey outlet moncler outlet woolrich outlet piumini duvetica moncler outlet moncler hombre botas ugg canada goose outlet ugg baratas canada goose dame parajumper norge moncler jakke parajumper salg
viagra wirkung viagra wirkstoff viagra naturel viagra homme viagra pour homme viagra alkohol viagra dosering levitra virkning viagra priser apotek kamagra bivirkninger cialis en om dagen viagra virkning cialis online danmark levitra generika kamagra gel cialis generika in nederland hvor kjøpe generisk cialis på nett i Norge
kamagra kopen in de winkel kamagra bijsluiter levitra bijwerkingen viagra kopen apotheek cialis bijwerkingen cialis kopen in nederland viagra bestellen levitra kopen kamagra bestellen moncler jas heren canada goose jas moncler jas woolrich jas dames canada goose sale peuterey jassen parajumpers jas woolrich jas
Comprare VPXL Comprare Red Viagra Comprare Cialis Jelly Comprare Levitra With Dapoxetine Comprare Cialis Super Comprare Kamagra Jelly Comprare Propecia Comprare Viagra Comprare Viagra Professional Comprare Cialis Professional Comprare Female Viagra Comprare Levitra Comprare Viagra Super Comprare Viagra Gold Comprare Kamagra Gold Comprare Tadalis SX Comprare Cialis Comprare Priligy Comprare Kamagra in nederland hvor kjøpe generisk cialis på nett i Norge
Kamagra Jelly Viagra Professional Kamagra 100mg Levitra 20mg Kamagra oral jelly 100mg Cialis Super Active Viagra Jelly Cialis Professional Tadalafil Eli 20mg Generisk Levitra 20mg Kamagra Smaksatta kamagra 100mg Viagra Generisk Levitra Generisk Levitra Original Tadalafil Eli 20mg Kamagra 100mg Viagra Kapslar Viagra Generisk Levitra Generisk Tadlafil
Viagra prijs Sildenafil kopen Viagra kopen in Nederland Kamagra Bruistabletten kopen Originele Levitra kopen Viagra kopen apotheek Viagra goedkoop Voordelen van viagra Propecia kopen Sildenafil kopen Haaruitval mannen Cialis kopen Viagra bijwerkingen Viagra werking Viagra kopen bij drogist Viagra pila>
Slimex Cialis Generico Viagra Levitra 20mg Meizitang Soft Gel Viagra Generico Super Kamagra Viagra y Cialis Viagra para mujeres Viagra poppers Kamagra Oral Jelly Viagra Cialis apcalis oral jelly Viagra Strips Levitra opiniones Viagra afecta fertilidad Levitra Generico Kamagra 100
nike shox hogan scarpe calcio Tiffany christian louboutin Scarpe Adidas superstar Scarpe Reebok Adidas Scarpe nike sb Scarpe nike air force air jordan adidas scarpe Tacchi
nike blazer michael kors Ray ban nike huarache Adidas Scarpe Abbigliamento Asics nike flyknit scarpe converse Scarpe air jordan scarpe da calcio nike free nike cortez nike roshe air max new balance oakley converse Scarpe Adidas scarpe Nike Scarpe louis vuitton Ray ban adidas Adidas superstar longchamp air max Cinture scarpe Puma Puma Scarpe Scarpe nike air max scarpe asics nike air force Saucony polo camicie Polo Ralph Lauren
adidas buty puma buty hollister sklep converse damskie louis vuitton torebki timberland buty nike air max damskie nike buty new balance damskie michael kors laukut polo ralph lauren suomi louis vuitton laukku adidas outlet nike outlet
viagra prezzo cialis originale levitra generico kamagra prezzo levitra senza ricetta acquisto kamagra viagra generico viagra originale kamagra gel viagra online cialis 5 mg levitra prezzo comprare viagra comprare kamagra comprare levitra comprare cialis cialis prezzo kamagra oral jelly