North Bay Village | Lincoln Health Supply

First Name

Last Name

Email

Phone

Date of Birth

Do you have Type 1 or Type 2 Diabetes?

Yes

No

Are you insulin treated?

Yes

No

Do you visit a doctor at least every six months?

Yes

No

Have you experienced one severe episode of low blood sugar (below 54mg/dL or 3.0mmol/L) where it altered your mental or physical state and needed help from someone else to treat the hypoglycemia?

Yes

No

Have you experienced multiple episodes of low blood sugar levels (below 54mg/dL or 3.0mmol/L) that continue to occur despite trying different medications and modifying your treatment plan?

Yes

No

Consent

By clicking “Submit” below, I hereby provide my express written consent authorizing Lincoln Health Supply to run a health insurance eligibility check and to request a prescription from my treating healthcare professional for a continuous glucose monitor and/or supplies. I further am providing such consent for Lincoln Health Supply to contact me at the telephone number I entered above concerning the FreeStyle Libre System, including text messages and telephone calls from humans. I understand that I am not required to provide my consent as a condition to purchase any products or services and that this offer does not qualify me for any prize or reward. Message and data rates may apply. Message frequency varies. Text HELP for help. Text STOP to unsubscribe to future messages. Click HERE for our Privacy Policy. Click HERE for our Terms and Conditions.