Edit, Download, and Sign the BD Ultra-Fine Diabetes Education Samples Order Form
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How do I fill this out?
To fill out this form, start by providing the name of your facility and contact details. Next, select the type and quantity of samples you need. Finally, don’t forget to include your medical license number if applicable.
How to fill out the BD Ultra-Fine Diabetes Education Samples Order Form?
1
Provide the name of your facility, business address, and contact details.
2
Indicate the number of new insulin patients you have per month.
3
Choose the types and quantities of syringes and pen needles you need.
4
Include your medical license number if you are not a hospital.
5
Fax the completed form to the provided number or call the specified phone number.
Who needs the BD Ultra-Fine Diabetes Education Samples Order Form?
1
New healthcare facilities needing sample supplies for diabetes education.
2
Clinics seeking complimentary samples to support diabetic patients.
3
Medical professionals monitoring patients new to insulin therapy.
4
Hospitals aiming to stock up on diabetic supplies for patient care.
5
Diabetes educators looking for high-quality insulin syringes and pen needles.
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How do I edit the BD Ultra-Fine Diabetes Education Samples Order Form online?
Editing this PDF on PrintFriendly is simple. Upload the document and use the editor to fill in the necessary fields. Save and download your completed form with ease.
1
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2
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3
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4
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5
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What are the instructions for submitting this form?
To submit this form, please fax it to 201-847-4111 or call 1-888-367-9539. Alternatively, you can submit the form online at www.BDdiabetes.com/hcp. Make sure to complete all required fields accurately to avoid any delays in processing your order. For additional assistance, you may contact BD Medical Customer Service at (888) 367-9539.
What are the important dates for this form in 2024 and 2025?
To ensure timely receipt of your diabetic supplies in 2024 and 2025, please submit your orders by January 1st of each year.
What is the purpose of this form?
The purpose of this form is to provide healthcare professionals with an easy way to order complimentary samples of BD Ultra-Fine insulin syringes and pen needles. These samples are invaluable for managing diabetic patients, especially those new to insulin therapy. By completing and submitting this form, healthcare providers can ensure they have the necessary supplies to educate and support their patients effectively.
Tell me about this form and its components and fields line-by-line.
- 1. Facility Name: Provide the name of your healthcare facility.
- 2. Business Address: Enter the complete business address including city, state, and ZIP code.
- 3. Contact Information: Provide a phone number, fax number, and email address for contact.
- 4. Medical License Number: Include the medical license number if not submitting as a hospital.
- 5. Sample Details: Select from a list of BD Ultra-Fine insulin syringes and pen needles and specify quantities.
- 6. New Insulin Patients: Indicate the number of new insulin patients you have per month.
What happens if I fail to submit this form?
If you fail to submit this form, you may not receive the necessary supplies for diabetes education.
- Delayed Supplies: You may experience a delay in receiving complimentary samples.
- Patient Care Impact: The lack of supplies could affect the quality of diabetes education and patient care.
How do I know when to use this form?
- 1. New Insulin Patients: Order samples for patients who are new to insulin therapy.
- 2. Diabetes Education Programs: Stock up on supplies for diabetes education programs.
- 3. Clinic Supplies: Ensure your clinic has the necessary supplies for patient care.
- 4. Hospital Supplies: Hospitals can order samples to provide quality care to diabetic patients.
- 5. Healthcare Professionals: Healthcare professionals use this form to obtain supplies for managing diabetic patients.
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Yes, you can use the sharing options to distribute the form via email or other methods.
Are there limits to the number of samples I can order?
Yes, there are specified limits on the number of cases or boxes you can order.
What type of information do I need to provide in the form?
You'll need to provide your facility's details, contact information, sample quantities, and medical license number if not a hospital.
Can I receive updates from BD Diabetes through this form?
Yes, you can opt-in to receive periodic email updates from BD Diabetes.
How do I submit the completed form?
You can fax the completed form to the provided number or call the specified phone number.
Is this form suitable for healthcare professionals only?
Yes, the form is designed for healthcare professionals to order complimentary samples for diabetes education.
Related Documents - BD Diabetes Samples Form
BD Diabetes Education and Samples Order Form
This file is a diabetes education and samples order form from BD Medical. It includes complimentary syringe and pen needle take-home kits and sample packs. Ideal for health care professionals managing diabetes patients.
