Diabetic Supply Re-Order - Ship Order

You have selected the Sparrow Regional Medical Supply Ship Order Form. Shipped orders will take 2 days and will be shipped via UPS. Orders placed on the weekend will be shipped on Monday or the next business day. (Free Shipping)
  

SECTION 1 - Address Information

Account Number:
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First Name:
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Last Name:
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Address:
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City:
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State:
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Zip Code:
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Home Phone: (Must include area code)
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Is this a new address:

YES! Please add my name to your email list and include me in special offers and notify me of shipment eligibility. I understand that by providing my email address I am giving Sparrow Regional Medical Supply permission to contact me via email.

SECTION 2 - Insurance Information

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Has your insurance coverage changed since your last order was filled.

SECTION 3 - Order Information

Please indicate the shipping address: (Orders that are shipped are processed at the Lansing location.)

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Ship to address provided in Section 1

Diabetic Supplies Needed

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Strips:

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Lancets:

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Solutions:

Comments about your order:
(Note: Insulin is not available through this process.)

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