Requirements for Service
The following forms and information are required for all
programs except the Pre-diabetes Program. If you have
questions, please contact the Inova Diabetes Center location where you
will be receiving services.
- The Inova Diabetes Center requires an order form or
prescription from your doctor in order to provide the appropriate
service. A physician prescription should clearly state your name,
diabetes diagnosis and be signed by the physician. To obtain the
Order Form for Diabetes Education to take to your physician, click here.
- Some insurance companies also require a letter of medical
necessity to cover our services. Please check with your insurance
company.
- When attending a class or individual appointment, you will need to
fill out an Assessment Form. This form may be mailed,
emailed, faxed or downloaded off our website. If you have not
completed the assessment form prior to attending your appointment,
please arrive 20 to 30 minutes early to allow adequate time to fill
this out.
Assessment Forms
- Type 1 or 2 diabetes program
(English)
- Type 1 or 2 diabetes program
(Spanish)
- Diabetes and pregnancy program
(English)
- Diabetes and pregnancy program
(Spanish)
- Pediatric assessment form
(English)
- Pediatric assessment form
(Spanish)
- Type 1 or 2 diabetes program
- In addition, you may be asked to complete a 3-day food and activity record prior to your appointment. Please
record food, beverage and portion sizes consumed and bring this
with you. Click here for a food record sheet.
- If available, please bring any current laboratory results,
such as hemoglobin A1C, glucose and lipid profile.
- Please bring insurance card(s) with you to each visit. For more details about financial information, click
here
- If you have a blood glucose meter, bring it with you to your appointment. If you do not have a blood glucose meter, we will try to provide you with one.
