ABBOTT DIABETES CARE HOSPITAL USE CGM ORDER FORM

THIS FORM IS FOR INTERNAL USE ONLY AND NOT TO BE EMAILED TO ANY HOSPITAL CONTACT

The FreeStyle LibreLink app is only compatible with certain mobile devices and operating systems. Please check freestylelibre.us for more information about device compatibility before using the app.

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Talking Points/Messaging:

Thank you for your interest in this special program. We are proud to be able to support and serve you in this special time of need. We have two options available for you. If you are a non-profit hospital we may be able to assist you with our partnership with Insulin for Life and supply your facility with these much needed devices at no cost to you. If you are not a non-profit facility we have a means for you to procure these devices as well. Before we proceed, we want to make you aware of some important information regarding this special program:
IMPORTANT: THIS PROGRAM IS INTENDED FOR INPATIENT USE ONLY
Hospitals should consider whether they have the resources and expertise necessary to adequately implement FreeStyle Libre 14 day system use in their facility and provide appropriate training to healthcare providers.
The FreeStyle Libre 14 day system should only be used in patients able to perform glucose scans themselves.
FreeStyle Libre 14 day glucose results are less accurate than blood glucose results obtained using traditional testing methods (e.g., lab glucose, blood glucose meters) in hospital settings. Users should consider all FreeStyle Libre 14 day glucose information (e.g., trend) along with individual glucose values, and interpret FreeStyle Libre 14 day results in the context of the full clinical picture.
The FreeStyle Libre 14 day sensor is subject to interferences that may generate falsely high and falsely low glucose readings. Levels of interference depend on drug concentration; substances that may not significantly interfere in non-hospitalized patients may interfere when used in the hospital setting because of higher dose levels. Most drugs used in hospital or critical care settings have not been evaluated and their interference with the FreeStyle Libre 14 day system is unknown. Known interferences include a significant positive bias due to high doses of ascorbic acid (Vitamin C) and a slight negative bias when taking salicylic acid (used in some pain relievers such as aspirin). Other reducing drugs/ compounds may also interfere.
Poor peripheral blood perfusion may cause inaccurate sensor readings. FreeStyle Libre 14 day results should be interpreted considering accompanying patient conditions and medications. Other clinical conditions may also cause inaccurate readings.

I have conveyed the above information to the contact :

Yes

Please ensure data accuracy and correct formatting as this data will be seen by the customer contacts, the Insulin for Life Team, the FSR Implementation team and your managers. Thank You.

Please fill in the order form below:

HOSPITAL INFORMATION:

Is this a Government Facility? ( VA, DOD, IHS, or PUBLIC HEALTH )

YES

Hospital Name: ( Under no circumstances are children's hospitals of any kind allowed to be submitted without expressed written consent from Abbott's OEC Team )

Order Type ( New = First time ordering CGM for this program - Re-Order = Subsequent Order for this program )

Abbott Account #:

Shipping Address Line 1

Shipping Address Line 2

Shipping City

Shipping State

Shipping Postal Code

ORDERING CONTACT INFORMATION:

First Name

Last Name

Phone

TRAINING CONTACT INFORMATION:

First Name

Last Name

Title

Phone

Specific training needs, questions, or concerns:

OPTIONAL - DATA MANAGEMENT CONTACT INFORMATION:

First Name

Last Name

Title

Phone

Specific data management needs, questions, or concerns:

ORDER INFORMATION:

PURCHASE ORDER NUMBER

SENSOR QUANTITY ( ORDER QTY MUST BE DIVISIBLE BY 24 ) ( EACH SENSOR HAS A MAXIMUM WEAR TIME OF 14 DAYS ) - SKU: 71940-01 - $57.70 EACH

READER QUANTITY ( OPTIONAL ) - ( ORDER MUST BE DIVISIBLE BY 4 ) SKU: 71938-01 - $70.00 EACH

Submitted By:

Please Select Your Name

I have reviewed the data for formatting and accuracy. I have checked email domains for consistency, and I verify that this is NOT a children's hospital.

Yes

When you hit submit, an order will be submitted immediately to either IFL or Customer Service, and an FSR will be automatically created, and the contacts above will be sent a confirmation email.

For more information on the FreeStyle Libre Pro 14 Day System Click Here