EasyTouch Enrollment Form

  • Patient Information
  • I UNDERSTAND THAT BY SIGNING BELOW CONFIRMS MY ENROLLMENT IN DIABETES SUPPLY CENTER OF THE MIDLANDS DBA DIABETES SUPPLY’S EASYTOUCH PROGRAM. BY ENROLLING IN THE EASYTOUCH PROGRAM I AUTHORIZE DIABETES SUPPLY TO CHARGE MY CREDIT CARD ANY OUT OF POCKET DUE AND TO SHIP SUPPLIES TO THE DELIVERY ADDRESS ON FILE.

    I ACKNOWLEDGE THAT I AM RESPONSIBLE TO NOTIFY DIABETES SUPPLY OF ANY CHANGES TO MY INSURANCE OR DELIVERY ADDRESS BEFORE THE NEXT SHIPMENT.

    I UNDERSTAND I AM ABLE TO OPT OUT OF THE EASYTOUCH PROGRAM AT ANY TIME. HOWEVER, REQUESTS TO OPT OUT OF THE PROGRAM MUST BE DONE 7 DAYS PRIOR TO THE NEXT SHIPMENT TO ALLOW FOR PROCESSING THE REQUEST.
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