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A1C Plan App Wait List
A1C Plan App Wait List Form
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* Indicates required question
A1C PLAN - Execute A Healthy Lifestyle
First Name
*
Your answer
Phone number (including area code)
*
Your answer
Do you currently have health care insurance?
*
Yes
No
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?
Yes
No
Clear selection
Do you have Type 1, Type 2 diabetes, prediabetes, or gestational?
*
Type 1
Type 2
Prediabetes
Gestational
Required
Do you use a Continuous Glucose Montior (CGM)
*
Yes
No
If you use a Continuous Glucose Montior (CGM), what brand?
Dexcom G6 or G7
Abbott Freestyle Libre 3
Other
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If you do not use a Continuous Glucose Montior (CGM) are you interested in learning about one?
*
Yes
No
Maybe
What was your last A1C (90 days)?
*
Lower than 6
6-9
10-12
13 or higher
When was your last eye exam?
*
In the last 3 months?
4 - 6 months?
7-12 months?
Over a year?
Other:
When was your last Podiatrist visit?
*
In the last 3 months?
4 - 6 months?
7 -12 months?
Over a year?
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