Diabetic Testing Supplies by John's Pharmacy

 

 1.800.540.9222
 information@johnsrx.com


 

Patient Information

Diabetic Testing Supplies by Mail

In order for us to serve you in the most time-sensitive and efficient manner, we'll need all the information below to start your John's Pharmacy file. When you have all the information handy, please call 1-800-540-9222 between 9 a.m. and 6 p.m. Monday through Saturday. One of our staff members will take your information in a matter of minutes, or just fill out our online form.

After we receive authorization from your physician regarding your prescribed treatment(s), the information below will facilitate the shipment of your diabetic testing supplies directly to your home. Please fill out as much information as possible.

Name  
E-mail address
Phone number   
Address
City
State 
Zip Code
Birth Date
Medicare Number
Are You on Insulin
Type of Test Strips Needed
Type of Lancets Needed
   
Supplemental Insurance Carrier Name
ID Number
Supplemental Insurance Policy Number
Supplemental Insurance Claims Address
City & State
Zip code
Supplemental Insurance Phone number
   
Doctor's Name
Address
City, State, & Zip code
Phone number
No. of Times Daily You test your Glucose

       

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