First Name * Last Name * Phone Number Date of Birth * Gender * MaleFemalePrefer Not To Say Email * Delivery Address City State —Please choose an option—AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code * Requested Orthotics Back BraceLeft Knee BraceRight Knee BraceLeft Shoulder BraceRight Shoulder BraceLeft Wrist BraceRight Wrist BraceLeft Ankle BraceRight Ankle Brace Requested CGM Device FreeStyle Libre 2 SystemFreeStyle Libre 3 SystemDexcom G7 SystemDexcom G6 SystemFreeStyle Lite ReaderFreeStyle Test StripsFreeStyle Lancets Your Doctor's Name * Your Doctor's Phone * Do you have a signed prescription? * YesNo Do you consent to Axis Medical Supply contacting you via phone, email, or text message regarding durable medical equipment and related services? * YesNo Do you authorize Axis Medical Supply to access and use your health information as necessary to process orders, verify insurance coverage, and coordinate your care? * YesNo Do you consent to Axis Medical Supply contacting your insurance provider to verify your benefits and obtain authorization for durable medical equipment?* YesNo Do you acknowledge that you are responsible for any charges not covered by your insurance plan, including copayments and deductibles?* YesNo Do you consent to receiving marketing communications from Axis Medical Supply about products, services, or offers? You can opt out at any time* YesNo Do you understand that you may revoke any of these consents at any time by contacting Axis Medical Supply?* YesNo