A1C Plan Platform Wait List 
A1C Plan Wait List Form
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                                           A1C PLAN - Execute A Healthy Lifestyle
Name *
Phone number (including area code) *
Do you currently have health insurance? *
What company covers your health insurance?
If you answered NO to having health insurance, we can assist you with finding coverage. 
Would you like our CARE Team to schedule a call to explain your options?
*
Do you have Type 1, Type 2 diabetes, prediabetes, or gestational? *
Required
Do you use a Continuous Glucose Montior (CGM) *
If you use a Continuous Glucose Montior (CGM), what brand?
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If you do not use a Continuous Glucose Montior (CGM) are you interested in learning about how to get a free or discounted CGM? *
What was you last A1C (90 days)? *
When was your last eye exam? *
When was your last Podiatrist visit? *
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