Not a patient yet? Request here

About you

First nameLast name Date of birth Mobile number E-mail (optional) Street addressCity

Your insurance

InsuranceChooseMedicareAlabama MedicaidBCBS of AlabamaHumanaOther Member ID (on your card) Photo of the card — front Photo of the card — back (optional)

Take the picture with your phone; it goes only to our office.

What do you need?

Tick everything that applies.

Continuous glucose monitor (Dexcom, FreeStyle Libre) Glucose meter, test strips and lancets Urinary catheters Ostomy supplies Incontinence supplies Wound care supplies Nebulizer and supplies Something else Tell us more (brand, size, how often you use it)

Are you using these now?

Yes No, this is new for me Who sends them to you now? (if anyone)

Your doctor

Doctor’s namePractice or clinic Office phone Office fax (if you know it)

When did you last see this doctor?

Within the last 6 months 6 to 12 months ago More than a year ago I am not sure

Anything else we should know? (optional) Port City Medical may contact my doctor to request a prescription and the medical records needed for my supplies. You may text me about this request (reply STOP any time).

Your answers go only to Port City Medical’s office over a secure connection. We use them only to set up your supplies.

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