Rx: Please check all that apply and provide refills
Medication / Supply
Insulin Lispro or Aspart Vial/Kwikpen
Regular Insulin (Humulin R/Novolin R)
NPH Insulin (Humulin N or Novolin N)
Glargine Insulin (Lantus or Basaglar)
Levemir FlexTouch / Levemir Vial
Tresiba FlexTouch or Toujeo Pen
Humalog 75/25 or 50/50
Humulin 70/30 or Novolog 70/30
Trulicity 0.75 / 1.5 / 3 mg
Ozempic PFP
Syringes or Pen Needles
Alcohol Pads
Test Strips
Lancets
Glucometer
Lancing Device
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