General
Year of Birth (of Monitor user) Gender Diabetes Type*
How many times per day do you test your blood glucose?
    
Are you newly diagnosed?
         Yes             No     
What type of insurance coverage do you have?
Medicare Medicaid No Insurance    
Other   
Where did you get your GLUCOCARD meter?
Physician Diabetes Educator Pharmacist TBD
Other
Where do you get test Strips?
Pharmacy Mail order Retailer I don't have a place
Pharmacy/Store Name, Address & Phone 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* Telephone
What type of meter do you have?* Monitor Serial Number (located on back of monitor)
Email Address
   
Please select one
Send me the free wellness kit in English
Send me the wellness kit in Spanish. Envieme el juego de bienestar en espaƱol.
I do not want to enroll in the free wellness program