Reorder-old My-DSS.com Resupply Request PATIENT INFORMATIONPatient Name(Required) First Middle Initial (optional) Last Suffix (optional) DOB(Required) Phone Number(Required)Email Address(Required) Supply InformationWhich supplies are you requesting today?(Required) CGM Supplies Insulin Pump Supplies Both Which CGM do you use?(Required) Dexcom G7 10-day Dexcom G7 15-day FreeStyle Libre 2 Plus FreeStyle Libre 3 Plus Other Please specify your CGM(Required)Are your current sensors expected to run out within the next 10 days?(Required) Yes No Which Insulin Pump do you use?(Required) Beta Bionics iLet Tandem t:slim X2 Tandem Mobi Other Do you need to reorder infusion sets, cartridges, or both?(Required) Infusion sets Cartridges Both Has Anything Changed?Has your shipping address changed?(Required) No Yes New Shipping Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Has your insurance changed?(Required) No Yes New Insurance Company(Required)Member ID(Required)New Insurance Card Photo (optional)Accepted file types: jpg, jpeg, png, heic, heif, Max. file size: 10 MB. Upload a clear photo of your new health insurance membership card.Has your diabetes healthcare provider changed?(Required) No Yes New Provider Name(Required)New Provider Phone Number(Required)Are you currently in a Skilled Nursing Facility, hospital stay, or rehab stay?(Required) No Yes Are you getting the same diabetes supplies from any other suppliers?(Required) No Yes Additional InformationIs there anything you'd like us to know?ConfirmationPatient Confirmation(Required) Check box to acknowledge confirmationI confirm that I am a current Diabetes Specialty Supply® patient and am requesting my next supply order.
