I acknowledge that Dexcom provides no warranties for the Samples other than the warranties outlined in the Instructions for Use.

I acknowledge that the Dexcom G6 cannot be used by multiple patients and agree not to reuse any items included in these Samples. I understand that Dexcom will be tracking, and if necessary, reporting and may be subject to disclosure requirements with respect to the provision of these Samples. I understand that these Samples will not be provided to any patients that are beneficiaries under the Maine or Colorado state Medicaid programs. Please note that if the patient of this pack is a Medicare beneficiary and the individual elects to continue using Dexcom G6 after this sample, the individual will need to obtain a medically necessary Dexcom receiver in order for Medicare coverage to be available. Accordingly, the treating healthcare provider should exercise their clinical judgment, in consideration of the Dexcom G6 Instructions for Use, to only dispense this pack to a patient who (or whose authorized caregiver) (i) has reliable access to a compatible smart device and/or automated insulin delivery system, and (ii) is capable of safely using the products in this pack with their smart device, without the need for a separate dedicated receiver.

In the event you determine that the Dexcom receiver is medically necessary for your patient during the limited evaluation period, the receiver can be separately purchased from Dexcom. This pack includes one (1) Dexcom G6 sensor and one (1) transmitter and does not include a dedicated receiver. Dexcom G6 is FDA cleared for use with a separate piece of durable medical equipment called a receiver. I understand that these Samples include packs containing the Dexcom G6 Continuous Glucose Monitoring System (“Dexcom G6”). I also agree to inform my patients that no claims may be submitted for any Sample Pack. I understand that these Samples are being requested for the medical needs of my patients and that I will not sell, resell, barter, return for credit or seek reimbursement for these Samples. All rights reserved.By submitting the above form, I certify that I am a licensed practitioner, authorized to request, receive, and dispense these Samples. in the United States and/or other countries. Dexcom is a registered trademark of Dexcom, Inc. I will comply with all applicable federal, state and local laws in receiving and dispensing these Samples, and I agree to store and use these Samples in a manner consistent with the Dexcom G6 Instructions for Use.

By submitting the above form, I certify that I am a licensed practitioner, authorized to request, receive, and dispense these Samples.

Dexcom gestr