Joining in a Research study has advantages:
close monitoring of your Diabetes and
access to some free medication or supplies.

Find out if you can join a study*:

• either fill in your medical information on the form below and we will answer shortly
  
• or let us take your information over the phone.
  
  *Have your medication list on-hand when filling the form.

Firstname:
Lastname:
City:
email:
Telephone:


Please check Yes or No to the following, as many as applies.

Anemia: Yes   No

Elevated triglycerides: Yes   No

Hypothyroid: Yes   No

Nephropathy: Yes   No

Osteoporosis: Yes   No

Diabetes Type 1: Yes   No

Diabetes Type 2: Yes   No

Depression: Yes   No

Heart Problems: Yes   No

Menopause: Yes   No

Neuropathy: Yes   No

Retinopathy: Yes   No

Elevated Cholesterol: Yes   No

Hypertension: Yes   No

Migraines: Yes   No

Obesity: Yes   No

Your current medication:

1. Medication:
   Dose: Start date:
   
   
2. Medication:
   Dose: Start date:
   
   
3. Medication:
   Dose: Start date:
   
   
4. Medication:
   Dose: Start date:
   
   
5. Medication:
   Dose: Start date:
   
   
6. Medication:
   Dose: Start date:

Please write your surgical history related to Diabetes (if any).

* All health information is treated by our Clinic as hightly confidential and is not shared.

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'; } $string_exp = "^[0-9 .-]+$"; if(!eregi($string_exp,$telephone)) { $error_message .= 'Please enter a valid phone number.
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