Year of Birth (of Monitor user)
What type of insurance coverage do you have?
    Medicare
Gender Medicaid
    Health Savings Account (HSA)
Year of Diabetes Diagnosis Flex Spending Account (FSA)
    I pay a co-pay at the pharmacy
Which type of diabetes do you have?
No Insurance
Diabetes Type* Other
   
Which Factors most influenced your choice of GLUCOCARD? (choose up to three).
How many times per day do you test your blood glucose? Physician's Recommendation
    Diabetes Educator Recommendation
    Pharmacist Recommendation
    Insurance Coverage
    Price of Test Strips
    Advertisement
    Other
    
Thank you for your answers
Please complete your name and contact information below and submit this form to activate the warranty on your new GLUCOCARD Blood Glucose Monitor.
First Name* Last Name*
Street Address*
City* State*
Zip* Date of Purchase
Telephone What type of meter do you have?*
UPC Code (barcode located on bottom of box) Monitor Serial Number (located on back of monitor)
Email Address*
Help manage your diabetes through small healthy changes by joining our YouChoose Wellness Program.
Enroll in YouChoose Wellness Program and receive more information on GLUCOCARD products.
Maneje su diabetes a través de pequeños cambios sanos alistandose en nuestro programa YouChoose.
Aliste en nuestro programa YouChoose y reciba más información sobre los productos de GLUCOCARD.