Riley hospital diabetes supply list

Prescription Refill List
Insulin and Related Supplies

Name _______________________________________ Date ______________________

Local Pharamcy Name/Address : __________________________________________________________
30 day/ 5 refills
90 day/ 3 refills
Mail Away Pharamacy Name/Address:______________________________________________________
30 day/ 5 refills
90day / 3 refills
*Check only those items that require a new prescription for refills *
Insulin (Vials)
B-D Insulin Syringe with Attached Needle
Syringe with Ultra- Fine Needle (12.7mm 1/2” 30G)
Syringe with Ultra- Fine Short Needle (8mm 5/16” 31G)
Syringe with Micro-fine IV Needle (12.7mm 1/2” 28G)
*Used with “severe insulin resistance” Other Syringe _______________________________________
Insulin Prefilled Pens
Insulin Pen Device/Cartridge
Insulin Pen Needles
BD Ultrafine
Novofine
Other Injectables

Prescription Refill List
Meter and Related Supplies

*Check only those items that require a new prescription for refills *
Lancet Devices
*(Generic to all devices EXCEPT Accu-Chek)
Accu-Chek Multiclix Drum (6 lancets/ drum) Use Only with Accu-Chek Multiclix Device Use Only with Accu-Chek Soft Clix Device
Blood Glucose Meters
Blood Glucose Test Strips

Roche-Accu-Chek
Roche-Accu-Chek
Accu-Chek Compact Plus (17 strips per drum) Digit (Incentives for testing and Nintendo game included) Contour USB (USB connects directly to computer) Contour Contour TS (simple with LARGE display – mail order only) Breeze 2 ( colors: tinked pink, purple fusion,classic blue) Breeze 2 disc (ten strips per disk- 100 per box) Freestyle Freedom Lite (simpler with larger display) Precision Xtra Ketone Strips (10 strips per box) LifeScan
One Touch Ultra Mini (small and simple) One Touch UltraSmart (MDI and testing: graphs and stats on meter screen) One Touch Ultra Link (works with Medtronic Insulin Pump) One Touch Ping Meter (works with the One Touch Ping Insulin Pump)
Other___________________________
Other___________________________
Prescription Refill List

Miscellaneous

Control Solution for __________________ meter Application for Juvenile Diabetes Research Foundation Application for American Diabetes Association Oral Medication Refills
______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ Insulin Pump Supplies
Animas – One Touch Ping Insulin Pump
(90 Degree Insertion Angle Infusion Set with Inserter) Inset (6mm)
Inset (9mm)
Inset 30 (13mm)
Comfort (17mm)
Comfort (13mm)
Contact Detach Infusion Set (6mm)
Contact Detach Infusion Set (8mm)
Insulet Omni Pod Insulin Pump
PDM (Personal Data Manager)
Medtronic Insulin Pumps
(90 Degree Insertion Angle Infusino Set) Quick Set (6mm)
Quick Set (9mm)
Quick Serter Insertion Device
(90 Degree Insertion Ange Infusion Set with Inserter) Mio Infusion Set
(20-45 Degree Insertion Angle Infusion Set) Silhouette 13mm
18” tubing (only available with 13mm) Silhouette 17mm
Silhouette 13mm (no tubing)
Insulin Pump Supplies
Medtronic Insulin Pumps
Miscellaneous Insulin Pump Supplies
Barrier Wipe (IV prep, Skin Prep, Bard)
Sure T (6mm)
Transparent Dressing (IV 3000)
Adhesive Solution (Mastisol)
Adhesive Remover (Unisolve Wipes)
Local Anesthetic (Emla cream, Elamax cream)
Sure T (8mm)
Sure T (10mm)
Soft set (6mm)
Soft Set (8mm)
Soft-serter Insertion Device
Accu-chek Spirit Insulin Pump
(90 degree Insertion Angle Infusion Set) Accu-chek Flex Link Plus (6mm)
Accu-chek Flex Link Plus (8mm)
Accu-chek Flex Link Plus (10mm)
Link Assist Plus Insertion Device
(20-45 Degree Insertion Angle Infusion Set) Accu-chek Tender (13mm)
Accu-chek Tender (17mm)
Accu-chek Rapid D (6mm)
Accu-chek Rapid D (8mm)
Accu-chek Rapid D (10mm)

Source: http://diabetes.health.usf.edu/documents/USFDiabetesCenterRxRefillForm.pdf