See If You Qualify – medpatientservices

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See If You Qualify

Millions of Americans are still suffering the pains and inefficiencies from outdated technology developed decades ago! But you don't have to anymore! Take this quick, 5 question survey to see if you qualify for the latest technology in glucose monitoring, and insulin control available at almost no cost to you.

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How Many Times Do You Test Glucose Levels Using a Finger Prick Test? *

2 or Less Times Per Day
3 Times Per Day
4 or More Times Per Day

How Often do You Inject Insulin? *

Twice a Day
Three Times a Day
Four or More Times a Day

What's Your Age? *

Younger Than 45
45-64
65+

What Insurance Provider do You Use? *

Medicaid
Medicare
Other Private Provider
I Am Uninsured

Do You Currently Use a Continuous Glucose Monitoring System *

Yes
No

Name *

First

Last

Email *

Phone *

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Form completed