Reorder Form Home Support: Reorder Form Have you never before ordered samples through our website?If so, please use this Order Samples form. Thank you! First Name Last Name Email Phone Phone Extension Yes, please send me email communications. Name of Prescriber Requesting Samples With which representative do you work? - Select -AubreighHaileyMahniMattMelanieKyleDon't Know What samples would you like to receive ? Accu-Chek Guide Me Sample Meter Insurance Coverage Information for Accu-Chek Products** Accu-Chek Guide Free Meter Voucher** Message Please specify in above message field if you would like different quantities from your previous shipment or if you have any questions or requests regarding the Accu-Chek Delivers program. For any product specific questions or concerns, please contact Accu-Chek Customer Care at 1-800-858-8072 for assistance. * Required field ** Valid email address required