Please print your information, sign form, and return to the address below.

code:  


Name:______________________________________

Address:____________________________________

City, State, Zip:_______________________________

Phone Number:_______________________________

Medicare Information
Medicare Number:____________________________

Date of Birth:________________________________		 I authorize you to contact my physician to obtain a prescription and process my Medicare order.

Signature:_________________________________________

Doctor’s Name:____________________________________

Address:_________________________________________

City, State, Zip:____________________________________

Phone Number:____________________________________
For Doctor’s Use Only
Signature:____________________________________________

NPI Number:_________________________________________
Mail Form to:        Tarheel Diabetic and Medical Supply, Inc.
       216 E. Broad Street
       St. Pauls, NC 28384

 

 

Click to Close