Edit, Download, and Sign the BD Diabetes Education and Samples Order Form
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How do I fill this out?
To fill out this form, you need to provide details about your facility and contact information. Indicate the quantity of each type of syringe and pen needle sample pack you need. Ensure to include your medical license number if applicable.
How to fill out the BD Diabetes Education and Samples Order Form?
1
Provide your facility and contact information.
2
Select the quantity of each syringe take-home kit you need.
3
Select the quantity of each pen needle take-home kit you need.
4
Select the quantity of each syringe sample pack you need.
5
Select the quantity of each pen needle sample pack you need.
Who needs the BD Diabetes Education and Samples Order Form?
1
Health care professionals managing diabetes patients.
2
Clinics requiring complimentary diabetes education samples.
3
Medical facilities needing syringes and pen needles for diabetes care.
4
Diabetes educators looking for tools to educate new insulin patients.
5
Pharmacies providing diabetes care supplies to their customers.
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What are the instructions for submitting this form?
To submit this form, you can choose one of the following methods: Fax to 201-847-4111; Call 1-888-367-9539; Visit www.BDdiabetes.com/hcp and click on Newsletter Registration. Ensure all provided information is correct to avoid any delays in processing your order. After submission, you can expect your complimentary syringe and pen needle samples to be delivered to your provided address.
What is the purpose of this form?
The purpose of this form is to allow health care professionals to order complimentary diabetes education and samples from BD Medical. It includes various syringe and pen needle kits and sample packs to assist in diabetes patient management. The form also gathers information about the facility and contact details to ensure accurate delivery and communication.
Tell me about this form and its components and fields line-by-line.
- 1. Facility Information: Enter the name of your facility, contact person, and address details.
- 2. Syringe Take Home Kits: Select the quantity of each listed syringe kit you need.
- 3. Pen Needle Take Home Kits: Select the quantity of each listed pen needle kit you need.
- 4. Syringe Sample Packs: Select the quantity of each listed syringe sample pack you need.
- 5. Pen Needle Sample Packs: Select the quantity of each listed pen needle sample pack you need.
- 6. Medical License Number: Include your medical license number if applicable, especially if not a hospital.
- 7. Contact Information: Provide your phone number, fax number, and email address for communication.
What happens if I fail to submit this form?
Failure to submit this form might result in not receiving the complimentary diabetes education and sample kits.
- No Samples: You will not receive the complimentary syringes and pen needles needed for patient care.
- Delayed Care: Your patients may experience delays in receiving necessary diabetes care supplies.
- Missed Updates: You may miss out on receiving periodic updates and best practices in diabetes care.
How do I know when to use this form?
- 1. New Patients: For providing syringes and pen needles to newly diagnosed diabetes patients.
- 2. Sample Replenishment: When your clinic needs to replenish its stock of diabetes care samples.
- 3. Educational Purposes: To educate patients on the correct usage of syringes and pen needles.
- 4. Clinical Trials: For clinics involved in clinical trials needing standardized diabetes care supplies.
- 5. Patient Support: To offer consistent support and supplies to your diabetes patient community.
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