Printable Medical Forms
Diabetes Travel Letter Medical Form


{Physician Name}

{address}

{city, state, zip}

{phone}

 

{date}

 

 

To whom it may concern,

 

My patient {Name} has {Type 1/Type 2} diabetes and it is imperative that the following devices, medications, and other listed items remain with them at all times during travel or otherwise.

 

{Brand} continuous glucose monitor (CGM)

Blood glucose meter, test strips, and lancets or finger-stick device

{Brand} insulin pump

{Brand} insulin

{Medication Name} medication

Syringes

Glucogon

Glucose tablets

{other emergency items}

 

Please contact me at {contact} if you need further information.

Sincerely,

 

{Physician Name}

 











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