Social Networks for Health Conditions

Limited-Time Offer for Diabetics To see if you qualify to receive a OneTouch^® Meter in the color of your choice at no charge, please provide the information required.

Do you have diabetes? *
Yes
No

Where Should We Send Your Free Meter?

Title*
First Name*
Last Name*
Address 1*
Address 2
City*
State*
Zip OR Postal Code*
Phone Number*
Email Address*
When were you diagnosed with diabetes?
Which color would you prefer? *
What is your relationship to the person with diabetes?*

What is the name of the blood meter that you use most often to test your blood glucose levels?*
How long have you had your meter?*
How often do you test your blood glucose?*
What methods do you use to manage diabetes? *
Insulin Shots
Insulin Pump
Pills
Diet
Exercise
Other
Shots Other than Insulin
How many shots of insulin do you take daily? *
How often, if ever, do you make adjustments to the amount of insulin you take? *
Date of Birth (mm/dd/yyyy)

Yes, I would like to receive diabetes-related information and promotional offers from LifeScan. I agree that my name, address, and other personally identifying information I provide will be available to LifeScan, its affiliates and companies that support LifeScan's business, and that LifeScan and its agents may contact me for my opinions related to LifeScan's business.

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