Request A Dexcom CGM Sample

Request a free Dexcom CGM sample

Personal, Diabetes & Doctor Information

To determine your eligibility for a Dexcom CGM sample, please provide us with your basic contact, doctor and insurance information. Eligibility exclusions may apply.

All fields marked with an asterisk (*) are required.

Are you a current Dexcom CGM user (or have you recently ordered)?

1. Therapy Coverage Information

Insurance Type

Patient Diabetes Type

Patient Diabetes Therapy

2. Personal Information

Patient First Name

Patient Last Name

Phone Number

Please enter a valid 10-digit mobile number. Do not include any special characters.

Shipping Address

City

Shipping State

Zip Code

Format: XXXXX-XXXX

Gender

Patient Date of Birth

3. Doctor Search & Selection

Select your doctor from the list and click submit at the bottom of the page.

The Dexcom CGM is a prescription-only medical device. Please provide your treating healthcare provider's information below to obtain a sample. Either Dexcom, or a service provider on behalf of Dexcom, will reach out to your healthcare provider to obtain a prescription for your Dexcom CGM sample.

Doctor Prefix

Doctor First Name

Doctor Last Name

Doctor State

4. Terms, Conditions & Final Submission

I acknowledge and understand that under this Dexcom sample program I am eligible to receive a Dexcom CGM (sensor and transmitter only). The purpose of this sample is to allow me, together with my prescribing healthcare provider, to evaluate the functionality of the Dexcom Continuous Glucose Monitoring (CGM) System for management of my diabetes and to evaluate whether the Dexcom CGM System may be right for me. I authorized Dexcom to use the protected health information I provided solely for the purpose of determining eligibility for a CGM sample.

I understand that I have no obligation to purchase any products or services from Dexcom, either as part of this sample program or after the sample period.

I understand that this Dexcom CGM sample does not come with a Dexcom receiver and that by my acceptance of the sample I represent to Dexcom that I have reliable access to a compatible mobile smart device and, if applicable, Tandem Control-IQ / Basal-IQ insulin pump or Omnipod 5, and I am capable of safely using a Dexcom CGM sample with my compatible mobile smart device, without the need for a separate dedicated receiver during the 10-day sample period.

I understand that my compatible mobile smart device must be charged and have a broadband signal to display my glucose readings and push alrets and that if it is not set up or used correctly, I may not receive glucose readings, alarms or push alerts.

I agree to use the Dexcom CGM sample in accordance with the included Indications for Use. I understand that if I have any concerns about my access to or ability to use a Dexcom CGM sample with a mobile smart device, I should not accept the Dexcom CGM sample for use, and should speak to my healthcare provider. I understand that this Dexcom CGM sample is being provided to me without charge and I agree that I will not sell, barter, return for credit or seek reimbursement for this sample from any source, nor will I give or transfer it to any other person to use.

I further represent to Dexcom that I meet the below eligibility requirements for the Dexcom CGM sample and that I authorize Dexcom to request a prescription for the Dexcom CGM from my treating healthcare provider, using the contact information that I provide.

I understand that Dexcom may modify or rescind this offer at any time without notice.

I authorize Dexcom, Inc. (“Dexcom”) to use and to disclose my health and demographic information to its affiliates and internally to communicate with me about products or services that may interest me.

I understand that Dexcom, Inc. may not condition treatment, payment, enrollment, or eligibility for benefits on whether I sign this Authorization. I understand that I may revoke this Authorization by emailing [email protected] (subject line “Revoke HIPAA Authorization.”) My revocation will not be effective to the extent Dexcom has already relied on this Authorization. If not revoked, this Authorization will expire one year from today. I understand that if my information is disclosed for the purposes described above, it is no longer protected by HIPAA. I also understand that I am entitled to a copy of this Authorization

I agree to Dexcom’s Terms of Use and Privacy Policy, and agree that Dexcom (or a service provider on behalf of Dexcom) may (1) use my information to communicate with me about Dexcom products, services and programs, or to provide me with information relating to my healthcare treatment, payment for healthcare, or other health information or care coordination services, in accordance with such terms; and (2) contact me at the phone number and email address set forth above, and use automatic dialing machines, automated, pre-recorded voice messages, and may send SMS/text messages. I understand that I may opt out at any time by texting “STOP” in return to a text or by calling Dexcom at 888-738-3646, and that my consent to this contact is not required for the purchase of Dexcom products or services. I understand that my service provider’s airtime, message and data rates may apply. In addition, I certify that I (i) am the patient referenced above or (ii) am the parent or legal guardian of the patient referenced above, and that I am at least eighteen (18) years of age. *

I also agree that Dexcom (and a service provider) may share my information with one of Dexcom's distributors that directly serve Medicare beneficiaries.

By clicking “Next,” or “Submit” I understand that I will have signed this Authorization. For more information: Dexcom's Notice of Privacy Practices.