Welcome to INPACT
Please answer all questions and we will contact you by email real soon. 
(Residents in Europe)
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Email *
First Name *
Last Name *
Telephone number (+ Country Code and telephone number) *
Sex *
Required
Date of birth *
MM
/
DD
/
YYYY
Date of diagnosis (if not sure, day 1 of month 1 of the relevant year) *
MM
/
DD
/
YYYY
Are you a caregiver? *
Ethnicity that you identify with *
Place of birth (country) *
Place of residence (country) *
Highest level of education attained *
How do you (or your loved one) manage your diabetes? Check all that apply *
Required
Have you ever participated in a clinical trial? *
Have you ever been a member of a PAC (Patient Advisory Committee)? *
Are you a member of a patient association? *
What are your languages? What level would you use to describe your fluency? Example: English, native; French, intermediate; Slovak, basic *
LinkedIn
Please enter your name on LinkedIn.
Facebook 
Please enter your name on Facebook or the name of your Facebook page.
Instagram
Please enter your handle(s) (without @).
X (formerly Twitter) 
Please enter your handle(s) (without @).
TikTok
Please enter your handle(s) (without @).
Blog
Please enter the full link to your website(s).
How did you learn about INPACT? *
Why would you like to become an INPACT Associate?
 *
Please, send your CV to inpact@innodia.org *
If you run into any problems when submitting this form, please try using a different email address. If the problem continues, contact inpact@innodia.org

By submitting this form you consent to the use of your personal data for organizational purposes of the INPACT Program in accordance with GDPR Regulations.
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