See if you qualify for a CGM System

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It looks like you may qualify for a CGM sytem. Fill out this form and a member of our Diabetes Care Team will be in touch with you regarding next steps. 

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

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Have you ever been on a Continuous Glucose Monitoring system before? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Newsletter Signup? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Can we email you about your order? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Unfortunately, you may not qualify for a CGM system at this time.

Most insurances, including Medicare, require that you need to test your blood glucose at least four times a day in order to qualify for CGM. You can still click "next" to continue filling out this form and we will contact you about your options.
Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Unfortunately, you may not qualify for a CGM system at this time.

Most insurances, including Medicare, require that you need to inject insulin at least three times a day or use an insulin pump in order to qualify for CGM. You can still click "next" to continue filling out this form and we will contact you about your options.
Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Unfortunately, you may not qualify for a CGM system at this time.

Most insurances, including Medicare, require that you frequently need to adjust your insulin levels in order to qualify for CGM. You can still click "next" to continue filling out this form and we will contact you about your options.
Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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{# pageNumbers}

Patient Info Continued

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

Insurance Info Continued

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Doctors Information

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Our Privacy Policy and HIPPA Policy

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{# pageNumbers}

See if you qualify for a CGM System

The email has been sent.

Your progress has been saved.

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See if you qualify for a CGM System

Type of Diabetes? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Test your blood sugar levels at least 4 times a day? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Use an insulin pump or inject insulin at least 3 times per day? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Frequently adjust insulin based on your blood sugar levels? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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It looks like you may qualify for a CGM sytem. Fill out this form and a member of our Diabetes Care Team will be in touch with you regarding next steps. 

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Insurance {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Choose your Continuous Glucose Monitor {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Choose your Continuous Glucose Monitor {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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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 }
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Choose your Continuous Glucose Monitor {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Have you ever been on a Continuous Glucose Monitoring system before? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Which CGM? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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When did you last receive supplies? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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What company did you previously receive supplies from? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Newsletter Signup? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Can we email you about your order? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
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Unfortunately, you may not qualify for a CGM system at this time.

Most insurances, including Medicare, require that you need to test your blood glucose at least four times a day in order to qualify for CGM. You can still click "next" to continue filling out this form and we will contact you about your options.
Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Unfortunately, you may not qualify for a CGM system at this time.

Most insurances, including Medicare, require that you need to inject insulin at least three times a day or use an insulin pump in order to qualify for CGM. You can still click "next" to continue filling out this form and we will contact you about your options.
Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Unfortunately, you may not qualify for a CGM system at this time.

Most insurances, including Medicare, require that you frequently need to adjust your insulin levels in order to qualify for CGM. You can still click "next" to continue filling out this form and we will contact you about your options.
Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Patient Info Continued

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

Insurance Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Insurance ID {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Insurance Group # {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Payer ID# {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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OR Upload a Picture of Your Insurance Card {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Doctors Information

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

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