Untitled Document

Title: *

Mr.

Ms.

Mrs.

Miss

First name: *

Last name:

Street Address: *

Must be a US resident in order to qualify.

City: *

Must be a US resident in order to qualify.

State: *

Must be a US resident in order to qualify.

Zip: *

Must be a US resident in order to qualify.

E-mail: *

Phone: *

Note: You will be contacted by a Family Diabetic Supply representative to verify your information.

Date of Birth:

Disclosure : *

Yes I understand

I understand that the information provided above may be used by Family Diabetic Supply for sales and marketing purposes and that this information may be shared with related or affiliated companies in the course of determining my eligibility for a free glucose meter.
This information will NOT be shared with any outside mass marketing companies.
If I am eligible for a free meter, I understand that I will be contacted by Family Diabetic Supply.
* Private insurance, Medicare or Medicaid is required to qualify for a free meter. Free meters are provided in conjunction with test strip fulfillment. Due to limitations imposed by some private insurance and Medicaid programs, not everyone will qualify for a free meter.
If it is determined that you do not qualify for a free meter through your private insurance, Medicare, Medicaid or other medical coverage, Family Diabetic Supply's third party provider may offer you discounted test strips in order to provide a free meter.

* Must be a US resident in order to qualify.