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Get your diabetes monitoring supplies
delivered to your door!
Call now! 1-800-408-0240
Local - 336-661-1669   Fax - 336-661-1678


  • Free Delivery right to your home.
  • We fill out all the insurance paperwork for you.
  • No claim forms to fill out - We do it for you.
  • No waiting for reimbursement.
  • Medicare, Medicaid and private insurances welcome.



Application
(Be sure to click SUBMIT button after completion)
Name of patient:  
Sex:
Address:  
City:  
State / Zip:  
Day Phone:  
Home Phone, if different:  
Date of Birth:  
Social Security Number:  
Medicare/Medicaid
or Other Insurance #: 		 
Physician Name:  
Physician Phone:  
Secondary Insurance:
Name of Insurance Co.:  
ID/Policy Number:  
Group Number:  
Insurance Phone:   
 
 
 

"Med-Co for LIFE"
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