Special Offer exclusively for LMC Patients: 15% off your 1st shipment if you join our Automated Supply Program between January 6, 2014 and April 15, 2014. Patient Name: Patient Address:
Phone Number: E-mail: Shipping Address (if different than above): Price $ Select Infusion Set
Quick-Set
Mio
Silhouette
Sure-T Select Paradigm Reservoir Size
Continuous Glucose Monitoring Sensors
Select one: MMT-394600 6mm/18” MMT-399600 6mm/23” MMT-387600 6mm/32” MMT-398600 6mm/43” MMT-397600 9mm/23” MMT-386600 9mm/32” MMT-396600 9mm/43” MMT-921600 6mm/18“ pink MMT-941600 6mm/18" blue MMT-943600 6mm/23" blue MMT-923600 6mm/23" pink MMT-965600 6mm/32" clear MMT-975600 9mm/32" clear MMT-368600 13mm/18” MMT-381600 13mm/23” MMT-383600 13mm/23" MMT-382600 13mm/43" MMT-378600 17mm/23" MMT-384600 17mm/32" MMT-377600 17mm/43" MMT-862 6mm/18" MMT-864 6mm/23" MMT-874 8 mm/23" Select one: MMT-326A 1.8 ml MMT-332A 3.0 ml Select one: MMT-7002C GLUCOSE SENSORS, 10/BOX MMT-7002D GLUCOSE SENSORS, 4/BOX MMT-7008A Enlite Glucose Sensors, 5/BOX
Quantity (BOX) (3 or 4)
186.26 186.26 186.26 186.26 186.26 186.26 186.26 192.90 192.90 192.90 192.90 192.90 192.90 186.26 186.26 186.26 186.26 186.26 186.26 186.26 156.03 156.03 156.03 39.38 39.38 479.75 192.90 322.19 Estimated Total $ Based on current price
Choose your delivery date: Please ship my supplies on the
10th or 20th (please circle one) starting in the month of
_______________ and continuing every 3 months thereafter. I understand that this agreement will renew automatically each year, on the anniversary of the first shipment date. I understand that to make any changes to this order (including cancelling this agreement), I must notify Diabetes Source in writing at least 10 business days before my next order is scheduled to ship. Please note the order placed with the 15% discount promo code on Diabetes Source will not be shipped until the completed Automated Supply Program form is received by Diabetes Source.
Choose your method of payment: I hereby authorize DiabetesSource to charge the above order to my credit card, 5 business days prior to my scheduled shipment date. Please note that the exact amount will be reported to you via email based on the retail price at the time of transaction.
Card Type: Cardholder Name (exactly as shown on card): _______________________________________________ Card Number: ________________________________________ Expiry Date (MM/YY): ______________ CVV: _________ Cardholder Signature: ___________________________________ Date:____________
Send us your order in one of 3 easy ways: 1. Email
2. Mail
3. Fax
Scan your signed copy to info@diabetessource.ca
1929 Bayview Avenue, Suite 106 Toronto ON, M4G 3E8
1-855-795-2701
Please carefully review the Terms and Conditions here: http://diabetessource.ca/terms-and-conditions/ I have reviewed and agree to the Terms & Conditions. Signature: ______________________________________________ Date: _________________________