Request A Dexcom CGM Sample

You’re one step closer to getting started with Dexcom.

Please fill out the form below. Once submitted, a Dexcom representative will review your information, check your Medicare benefits, and work with your doctor to request a prescription.

Personal & Diabetes Information

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

Personal Information

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

Patient First Name

Patient Last Name

Phone Number

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

Zip Code

Format: XXXXX-XXXX

City

Gender

Patient Date of Birth

Therapy Coverage Information

Insurance Type

Patient Diabetes Type

Patient Diabetes Therapy

Do you have a preferred medical supplier?

Diabetes Supply Purchase Source

Doctor & Insurance Provider Information

All fields marked with an asterisk(*) are required

Doctor First Name

Doctor Last Name

Doctor Phone Number

Please do not include any special characters.

Doctor City

Doctor Zip Code

Format: XXXXX-XXXX

Insurance Provider

Insurance Member ID

RxBIN

Processor Control Number (PCN)

Insurance Customer Service Phone Number

No special characters.

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.