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Enrollment Form

You are only 3 easy steps from having Free Diabetic Supplies Delivered Right to your door. It's Simple, It's Easy.

Just fill out the from below to find out if you qualify to have Diabetic Supplies delivered for little to No cost to you.

Enter your shipping and contact information.

  • We provide free delivery, anywhere in the country.

First Name MI Last Name
Street Address 1 City
Street Address 2 State Zip Code
Email Address Gender Date of Birth
Phone Number When is the best time to call you?
 -   - 
Alternate Phone Number
 -   - 

Enter your physician's information.

  • We will contact your physician for you to obtain a valid prescription for diabetes.

Physician's Name Physician's Phone
 -   - 

Enter your Medicare or private insurance information.

  • We'll provide a free insurance verification for diabetes supply coverage.
My Insurance is:
How many times a day do you
test your blood sugar level? 
Do you inject insulin?


Once you've completed these 3 easy steps, one of our representatives will contact you. Find out why thousands of people are getting their diabetic supplies through Online Diabetics Online.

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