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Take The Survey

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Take The Survey

Take the survey, see if you qualify for Dexcom G6!

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Step 1 of 6

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Ready to get started?

Complete our brief screening to see if you pre-qualify for a Dexcom G6 CGM System.

Name(Required)

First Last

Email(Required)

Phone(Required)

Do you accept our terms and conditions?(Required)

By clicking here you agree to our terms of use, privacy policy, and cookie policy.

I agree

Are you Diabetic?(Required)

Yes

Does your current diabetes management include insulin administration?(Required)

Yes

Roughly how many times a day do you administer insulin?(Required)

Do you use an insulin pump?(Required)

Yes

Are you currently using a CGM?

Yes

How often do you visit your doctor about your diabetes?(Required)

Every 4 weeks or less

Every 6 weeks

Every 8 weeks

Every 12 weeks

Every 6 months

Yearly

Do you have an endocrinologist?(Required)

Yes

Name of your Endocrinologist

Phone number of your Endocrinologist

Address(Required)

Street Address Address Line 2 City State ZIP Code

Date of Birth(Required)

Month

Day

Year

Gender(Required)

Please Specify Gender(Required)

Primary Insurance Provider(Required)

Please Specify Insurance Provider

Is your insurance an HMO or PPO?(Required)

HMO

PPO

No Sure

What CGM would you like(Required)

This field is hidden when viewing the form

Current Age

Your Doctor's First & Last name(Required)

In what state do they practice?(Required)

In what city do they practice?(Required)

Comments

This field is for validation purposes and should be left unchanged.

By completing this form and pressing “Submit”, I acknowledge, accept, and expressly agree that agents or representatives from St. Joseph Medical may contact me via SMS or other means regarding continuous glucose monitoring at the contact information I provide here. Please note that no agent or representative from St. Joseph will contact you before 8 am or after 9 pm in your time zone, and our team will specifically indicate that they are contacting you from St. Joseph Medical.

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