Tell us more about you:

	*First Name
	*Last Name
	*Daytime Phone	ext.
	*Evening Phone	ext.
	*Address
	Alt Address
	*City
	*State	Select One AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VT WA WI WV WY       *Zip:
	*Email Address
	*Date of Birth of Meter User
	Month Day Year
	*When were you diagnosed with diabetes?
	Month Year
	*What promotion are you responding to?
	Select One TV Commercial Direct Mail E-mail Caring Today Website Spotlight Pharmacy Physician Reader's Digest
	How often do you test your blood glucose?
	Select One 1 X per day 2 X per day 3 X per day more than 3 X per day Less that 1 X per day 4 or more times per day 4-6 times per week 1-3 times per week Less than 1 time per week
	Which glucose meter were you previously using?
	NONE: 1st time user Abbott Precision Xtra™ / Qid AccuChek Advantage® CONTOUR® AccuChek Active® ELITE® or ELITE® XL AccuChek Compact® DEX®2 AccuChek Aviva® BREEZE® One Touch® Ultra® / Smart® BD Logic® / Latitude™ Freestyle® / Flash™ Other
	How do you treat your diabetes?
	Insulin Injections Both insulin and oral medication Insulin Pump Diet and exercise Oral Medication Other...
	If other, please explain
	Where did you receive your previous meter?
	Retail Store - Name:
	Insurance Company - Name:
	Mail Order Company - Name:
	Internet Distributer - Name:
	Other - Name:
	Where do you expect to get your supplies for this meter?
	Retail Store - Name:
	Insurance Company - Name:
	Mail Order Company - Name:
	Internet Distributer - Name:
	Other - Name:
	What type of insurance for your blood glucose meter and strips?
	No Coverage
	Medicare
	Medicaid
	Managed care plan or Private Insurance:
	Name of plan
	Other...
	Please explain
	Do you test your blood in areas other than your finger tips?
	Select One Yes No
	Check this box if you do not want be contacted or sent additional information on diabetes. Bayer products and services, and future offers.
	PRIVACY STATEMENT: Bayer respects your right to privacy. Your personal and medical information will be kept confidential. It will not be shared with any third parties or outside mailing lists.

Accu-Chek^® Advantage^® is a registered trademark of Roche Corporate/Roche Diagnostics
Accu-Chek Compact^®and Accu-Chek Active^® are trademarks of Roche Corporate/Roche Diagnostics
BREEZE^®, CONTOUR^®, Ascensia^® DEX^® 2, Ascensia Elite^® and Ascensia Elite^® XL are all trademarks of Bayer HealthCare
BD Logic™ is a trademark of Becton, Dickinson and Company
One Touch^® Ultra^® and One Touch^® Basic^® are registered trademarks of Johnson&Johnson
Precision QID^® is a registered trademark of Abbott Laboratories
Therasense Freestyle^® Flash is a registered trademark of Abbott