Use this form to contact Input:JDRF for help with accessing diabetes technology.
Please answer these few questions to help us to help you.
Our goal is to respond within 3 working days.
We will address you by name when we respond to you. This will also help us to find your details if you contact us again in the future.
Your email address
Please make sure it is correct or we won't be able to respond to you!
Are you contacting us about yourself or someone else?
Mark only one option
Myself - it's about me
Someone else - my child, parent, friend, colleague, patient, etc
Which type of diabetes do you/does the person you're contacting us about have?
This information helps us to provide the most appropriate answer. Mark only one option.
Type 1 diabetes (and currently under 12 years old)
Type 1 diabetes (and currently between 12 and 18 years old)
Type 1 diabetes (aged over 18)
Type 2 diabetes
Other type / none
I am a healthcare professional
Your GP's surgery name and town/city (or your country if outside UK)
This will help us give the most relevant information, and give us the chance to review local policies before we reply to you.
Knowing your current treatment will help us to help you more efficiently. Select only one option
1 - 3 injections per day
4 or more injections per day
Glucose monitoring (optional)
Knowing how you currently measure your glucose levels will help us give you the most appropriate information for your situation.
Flash glucose monitoring (self-funded)
Flash glucose monitoring (NHS-funded)
Your comment / question:
How can we help you?
I am happy for you to securely store the information I have given you
Please do NOT store my information. I understand that this means I will have to provide all my information again if I contact you in the future.
Never submit passwords through Google Forms.
This form was created inside of Juvenile Diabetes Research Foundation.
Terms of Service