PATIENT INFORMATION
Patient Name: Date of Birth:
Address: Phone:
City: Province: Postal Code:
Email (optional):
STATEMENT OF MEDICAL NECESSITY
Diabetes Type: c Type 1 c Type 2 c Gestational
Diabetes Therapy: c Multiple Daily Injections ( injections per day)
c SMBG tests ( tests per day)
c Insulin pump - (start date: / / )
c Compliance with prescribed dietary and insulin regimens
SUPPORTING CLINICAL INDICATIONS
c Motivated to achieve and maintain improved glycemic control
c Demonstrated ability to self-monitor blood glucose levels
c Demonstrated ability to self-manage glucose using insulin (long acting, fast acting)
c History of hypoglycemia unawareness
c History of severe glycemic excursions
c History of nocturnal hypoglycemia
c Recurring episodes of severe hypoglycemia
c Unexplained, severe hypoglycemia episodes requiring external assistance for recovery
c Other:
PHYSICIAN INFORMATION
Physician Name: Oce Contact:
Hospital/Clinic Name: Phone:
Address: Fax:
City: Province: Postal Code:
Email (optional):
This document serves as a Prescription and Statement of Medical Necessity for the above referenced patient for a Dexcom
Continuous Glucose Monitoring (CGM) System, Dexcom CGM Sensors, Dexcom CGM Replacement Transmitter or Dexcom
CGM Replacement Receiver and all associated diabetes supplies to be provided by Dexcom Canada, Inc. NO SUBSTITUTIONS.
I certify that I am the physician identified in the above section and I certify that the medical necessity information contained in this document is true, accurate and complete, to
the best of my knowledge, and I understand that any falsification, omission, or concealment of material fact in that section may subject me to Civil or criminal liability.
Signature: Date:
Dexcom Canada, Co.
501 – 4445 Lougheed Hwy
Burnaby, BC V5C 0E4
Certificate of Medical Necessity
Continuous Glucose Monitoring (CGM) System
Please return by email to CA.Sales.dc@Dexcom.com, by toll free fax to 1-844-348-0784
or by regular mail to: Dexcom Canada, Inc. 501 – 4445 Lougheed Hwy, Burnaby, BC V5C 0E4
© 2020 Dexcom Canada, Co. LBL015263 Rev004
HbA1c Result #1: Date:
HbA1c Result #2: Date:
HbA1c Result #3: Date:
OPTIONAL
HbA1c results only required
for some insurance providers:
Manulife, OTIP, Johnson
Insurance, and Manion Wilkins.
click to sign
signature
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