A1C Plan App Wait List 
A1C Plan App Wait List Form
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                                           A1C PLAN - Execute A Healthy Lifestyle
First Name *
Phone number (including area code) *
Do you currently have health care insurance? *
If you answered NO to having health care insurance, we can assist you with finding coverage. 
Would you like our CARE Team to schedule a call to explain your options?
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Do you have Type 1, Type 2 diabetes, prediabetes, or gestational? *
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 one? *
What was your last A1C (90 days)? *
When was your last eye exam? *
When was your last Podiatrist visit? *
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