This is our printable order form. Please use this to order by fax or mail.

Please ship to:

Name:_________________________________________________________________________

Address:________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Phone ___________________________ Email _________________________________________

Payment Information:

I would like to pay by (circle one):  Check   MasterCard   Visa

Credit Card Number:__________________________________________ Exp _____________

Name on Card _______________________________________________________________

Signature ___________________________________________________________________

Please mail or fax this form to:

Diabetic Solutions
520 Orchard Falls St.
Spring Lake, NC 28390