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Do you have diabetes?  *

What is your relationship to the person with diabetes?  

Please answer the above question.

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YOUR CONTACT INFORMATION - fill out this section with your own contact information, and not anyone else's.
Accepted format xxx-xxx-xxxx
Accepted format xxx-xxx-xxxx
DIABETES INFORMATION - for you, or the person who has diabetes.

When were you diagnosed with diabetes? 

How often do you test your blood glucose?   

Please answer the above question.

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How many shots of insulin do you take per day?    

Please answer the above question

How often, if ever, do you make adjustments to the amount of insulin you take?    

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Was this meter provided at no charge?  *

Where did you receive your meter?  *

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Please Select a Number

LFS-14-4253B