See if you qualify for a CGM System

{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{# pageNumbers}

You have a high likelihood of being qualified for an insurance paid for CGM. Fill out this form and we'll get started.

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

We may not be in network at this time. Continue with the form and we will contact you asap to explain all your options! We'll get your insurance info a little later in the form.

{ binding firstError.message }
{ binding firstError.message }
YesNo NoYes
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
YesNo NoYes
{ binding firstError.message }
YesNo NoYes
{ binding firstError.message }
{ binding firstError.message }

Unfortunately you most likely will not qualify for a CGM system at this time.

Most insurance, including Medicare, require that you need to test your blood glucose at least four times a day. But you can click next and keep filling out this form and we will contact you about our diabetic Supplies. "We Care for the Communities We Serve."

{ binding firstError.message }

Unfortunately you most likely will not qualify for a CGM system at this time.

Most insurance, including Medicare, require that you need to inject insulin at least three times a day or use an insulin pump. But you can click next and keep filling out this form and we will contact you about our diabetic Supplies. "We Care for the Communities We Serve."

{ binding firstError.message }

Unfortunately you most likely will not qualify for a CGM system at this time.

Most insurance, including Medicare, require that you frequently need to adjust your insulin levels. But you can click next and keep filling out this form and we will contact you about our diabetic Supplies. "We Care for the Communities We Serve."

{ binding firstError.message }
{# pageNumbers}

Patient Info Continued

{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Shipping Address (If different from above) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{# pageNumbers}

Insurance Info Continued

{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{{ Cognito.resources['fileupload-dropzone-message'] }}
{binding Name, mode=oneTime}
{binding Description}
{ binding firstError.message }
{ binding firstError.message }

Doctors Information

{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
YesNo NoYes
{ binding firstError.message }

Our Privacy Policy and HIPPA Policy

{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{# pageNumbers}

See if you qualify for a CGM System

The email has been sent.

Your progress has been saved.

{ binding firstError.message }

See if you qualify for a CGM System

Type of Diabetes? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Test your blood sugar levels at least 4 times a day? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Use an insulin pump or inject insulin at least 3 times per day? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Frequently adjust insulin based on your blood sugar levels? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

You have a high likelihood of being qualified for an insurance paid for CGM. Fill out this form and we'll get started.

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Insurance {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Choose your Continuous Glucose Monitor {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Choose your Continuous Glucose Monitor {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

We may not be in network at this time. Continue with the form and we will contact you asap to explain all your options! We'll get your insurance info a little later in the form.

Choose your Continuous Glucose Monitor {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Choose your Continuous Glucose Monitor {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Have you ever been on a Continuous Glucose Monitoring system before? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Which CGM? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
When did you last receive supplies? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
What company did you previously receive supplies from? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Newsletter Signup? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Can we email you about your order? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
{ binding firstError.message }

Unfortunately you most likely will not qualify for a CGM system at this time.

Most insurance, including Medicare, require that you need to test your blood glucose at least four times a day. But you can click next and keep filling out this form and we will contact you about our diabetic Supplies. "We Care for the Communities We Serve."

{ binding firstError.message }

Unfortunately you most likely will not qualify for a CGM system at this time.

Most insurance, including Medicare, require that you need to inject insulin at least three times a day or use an insulin pump. But you can click next and keep filling out this form and we will contact you about our diabetic Supplies. "We Care for the Communities We Serve."

{ binding firstError.message }

Unfortunately you most likely will not qualify for a CGM system at this time.

Most insurance, including Medicare, require that you frequently need to adjust your insulin levels. But you can click next and keep filling out this form and we will contact you about our diabetic Supplies. "We Care for the Communities We Serve."

{ binding firstError.message }

Patient Info Continued

Date of Birth {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Gender {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
How would you like to receive your supplies? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Shipping Address (If different from above) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Emergency Contact Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Relationship {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Their Phone Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
{ binding firstError.message }

Insurance Info Continued

Insurance Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Insurance ID {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Insurance Group # {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Payer ID# {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
OR Upload a Picture of Your Insurance Card {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{{ Cognito.resources['fileupload-dropzone-message'] }}
{binding Name, mode=oneTime}
{binding Description}
{ binding firstError.message }
{ binding firstError.message }

Doctors Information

Physician Name* {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Physician Phone Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Physician Practice Name* {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
City of Physician Practice* {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
{ binding firstError.message }
I have viewed Bedard Medical Supplies Privacy and HIPPA Policy {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

Our Privacy Policy and HIPPA Policy

How did you hear about us? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Printed Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }