ABBOTT DIABETES CARE - GOVERNMENT ORDER REQUEST FORM

Please fill in the order form below:

Account Information:

Abbott Account #:

Formal Abbott Account Name:

Shipping Address On File ( if shipping address is incorrect, please detail in comments below )

Ordering Contact

First Name

Last Name

Government Channel Selection:

Please select the Government Channel you are part of:

DoD CGM Reader Program Announcement

Valued DoD Customers!!!

Are you aware that you can now order readers for Abbott's #1 Continuous Glucose Monitoring System, FreeStyle Libre 2 and FreeStyle Libre 3, right here?

Use this form to order FreeStyle Libre Readers for your facility!!

Available on the Tricare Uniform Formulary!! LIVE NOW!!

Learn More about FreeStyle Libre CGM here

DoD Order Type

BGM Outpatient Meter ( Multiple Platforms )CGM Outpatient Reader ( FreeStyle Libre 2 & FreeStyle Libre 3 Now Available )

CGM Reader Request Information:

Please Select Reader Platform Below:

Purchase Order # ( If left blank we will use your name as PO )

Quantity of Readers Requested ( Must be in QTYs of 4 ):

Please add any additional comments or shipping instructions here:

BGM Meter Ordering Instructions and Guidelines:

Please read and check each guideline:

Instructions for meter distribution: Meters should be given to newly-diagnosed patients or those who are using a non-Abbott meter. If a patient is already using an Abbott meter or has received a meter during the warranty period, the patient should not receive a second meter unless it is deemed that patient care will be negatively impacted.If a patient has a broken or malfunctioning meter: Check to make sure the battery is not dead and replace as necessary. If the device is malfunctioning or broken, please have the patient call the Customer Support number located on the reverse of the meter. In most circumstances, a no charge replacement will be shipped by express mail directly to the patient.If a patient has misplaced their meter or desires another meter for home, work, etc: Under the current meter distribution arrangement, patients are afforded one (1) no-charge meter during the warranty period, unless it is deemed that patient care will be negatively impacted.

Please answer these few questions in order for us to fulfill you meter request:

Please select the meter requested:

If ordering more than one meter type please submit a separate order form.

How many new patient starts do you anticipate providing meters to in the next 60 days?

How many patients do you anticipate switching to an Abbott Glucose Meter in the next 60 days?

How many new meters/meter cards are you requesting for the next 60 days?

Meters ship in quantities of 4.

Additional Comments and/or Special Shipping Instructions

For assistance or questions call 1-800-401-1183 and Press 4 For Government Support

Contact Information