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Person with Diabetes

First Name

Last Name

Date of Birth

Month

Day

Year

Parent/Legal Guardian

First Name

Last Name

Type of Diabetes

Selection 1 Type 1

Selection 1 Type 2: Using Insulin

Selection 1 Other/Unsure

Current Diabetes Treatment

Selection 1 Insulin Pump

Selection 1 1-2 Injections per day

Selection 1 3+ Injections per day

Contact Information

Phone

Selection 1 I certify I am 18 years of age or older. If you are under 18, please ask your parent or guardian to complete on your behalf.

Selection 1 I acknowledge I have been provided access to the Insulet Corporation Privacy Policy and the HIPAA Privacy Notice concerning the use and disclosure of my medical information.

Selection 1 I authorize Insulet Corporation, its distributors, affiliates and wholly-owned subsidiaries (“Insulet”) to contact me by telephone or e-mail regarding Omnipod and other diabetes related supplies and services.