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Physician Referral Form

Arriva Medical offers a quick and easy way for healthcare professionals to refer patients for convenient home delivery of diabetes testing supplies. Once enrolled, patients will always have supplies on hand in order to adhere to their doctor’s prescribed diabetes treatment regimen.

Our simple Physician Referral Form provides thousands of physician practices across the country with a simple process to enroll patients in our mail order program:

  1. Fill out and then print the Physician Referral Form:  click here
  2. Have the patient and the referring physician sign the form.
  3. Fax the form to Arriva Medical via fax number 800-272-1789


Click on the form now to get started!

If you want to check the status of your patients’ order or if you have any questions or comments about our referral program, please call our Physician Relationship Specialists at 800-204-2191.