Speciality Shoes and Diabetic Supplies

Diabetic Referral Form
Patient Name:
Physical Address:
City:	State: Zip:
Phone:
Date of Birth:
I am interested in: (check all that apply)
	Diabetic Shoes Supplies Vacuum Therapy Device
By submitting this information, I authorize Speciality Shoes and Diabetic Supplies to contact me by phone to help determine if my supplies are covered by Medicare.

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