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BayerDiabetes.com
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To join the Bayer Care Program please complete the following information.

All fields with an asterisk are required.

* Title :
* First Name :
Middle Initial :
* Last Name :
* Street Address :
Street Address :
* City :
* State :
* ZIP :
* Home Phone :
* Email :	(this will be your username)
* Password :
* Re-type Password :

Date meter purchased/obtained :	(MM/DD/YYYY)
Meter Serial Number :	help

* Your date of birth :	(MM/DD/YY)

* How often do you test your blood glucose?
	More than twice a day Twice a day Once a day Not every day
* How do you control your diabetes?
	Insulin injections/needles Oral medications/pills Diet and exercise Insulin pump Both insulin and oral medication Other
* What type of health insurance do you have for your meter and strips?
	No Coverage Medicare Medicaid Managed care plan or private insurance (e.g. Aetna, United Healthcare, Anthem BC/BS) Medicare plus other coverage Other
* What blood glucose monitoring system, if any, were you previously using?
	NONE, first time user Abbott Precision Xtra/Qid AccuChek® Active AccuChek® Advantage AccuChek® Aviva AccuChek® Compact/Plus Ascensia ELITE® or ELITE® XL Ascensia® DEX® 2 BD Logic/Latitude BREEZE®/BREEZE®2 CONTOUR® Freestyle®/Flash®/Lite® OneTouch® Ultra®/Ultra Smart®/Ultra2® Contour TS Other
* Where will you purchase your strips?
	Retail pharmacy Mail order Other
* Have you purchased strips for your new Bayer meter?
	Once Two-three times Four or more times Not yet

	Remove my email address from all communications
	Remove me from all Bayer communications (email, direct mail, phone and fax)

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