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Prescription Form and Statement of Medical Necessity   To submit a prescritpion form online, please complete the form below This is for the purchase of an AdvantaJet® for: Current Patient Information Injections per day: Blood glucose level ranges: Last glycohemoglobin level at: Diagnosis (check all that apply):   250.13 Diabetes with ketoacidos is, IDDM, uncontrolled   250.23 Diabetes with hyposmolar coma, IDDM, uncontrolled   250.33 Diabetes with other coma, IDDM, uncontrolled   250.43 Diabetes with renal manifestations, IDDM   250.53 Diabetes with opthalmic manifestations, IDDM   250.63 Diabetes with neurological manifestations, IDDM, uncontrolled   250.73 Diabetes with peripheral circulatory manifest, IDDM, uncontrolled   250.83 Diabetes with other specified manifestations, IDDM, uncontrolled   250.03 Diabetes without mention of complications, IDDM, uncontrolled   440.23 Atherosclerosis of extremities with ulceration   440.24 Atheroisclerosis of extremities with gangrene   440.29 Other atherosclerosis of the extremities   788.41 Urinary frequency   788.42 Polyuria   788.43 Nocturia other: Existing circumstances that could be remedied through use of the AdvantaJet®  Non-adherence to recommended injection frequency  Injection site Lipoatrophy/Lipohypertrophy  Erratic insulin absorption  Erratic blood glucose ranges  Difficulty using syringes related to:poor vision, decreased peripheral sensation,        decreased motion strength.  other: Insulin therapy is an absolute necessity for this patient. The AdvantaJet® provides a means of delivering the insulin more effectively than by needle and syringe. Benefits include better absorption, elimination of skin trauma, accuracy of dosage, and increased choice of injection sites. Economically, the AdvantaJet® is meant to be a one-time expense. Due to the fact that s'rringes are eliminated, the expense of the AdvantaJet® will be recouped in 2.5 to 3 years. Insulin dosage is often reduced, in some cases as much as 10-20%. D.E.A. #: Name of Physician: Practice: Address: E-maill Address: Phone Number: Patient Name: Date: Order for One AdvantaJet®