American Medical Supplies

* Some restrictions apply

Account Information

Name:

Address:

City:

State:

Zip:

Phone:

Email:

Doctor:

(if any changes)

Doctor's Phone:

(if any changes)

Please send the following Medicare covered items:

Have you changed your meter? Yes No

If yes, name of your new meter:

	Test Strips
	Lancets
	Control Solution
	Batteries
	Lancing Device
	Heating Pads (Please call for details)
	Erectile Device (Please call for details)
Notes:

American Medical Supplies, Inc. can only accept
returned items within 90 days from date of receipt.

Would you like to refer a family member or friend?

Name:

Phone:

May we use your name when calling? Yes No