EasyTouch Enrollment Form Patient InformationPatient Name:*Date of Birth (DOB):* 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.ENROLLMENT OPTIONS: Enrollment for all orders in 2020 Enrollment for orders when out of pocket estimate is $0 Patient/Guardian Signature:Date Guardian Printed Name: This iframe contains the logic required to handle Ajax powered Gravity Forms.
