Agents of Change

The Arizona Agents of Change initiative aims to move the needle on prediabetes screenings and treatment in our state.

Complete this simple and free registration to join other practices in reversing the course of diabetes in Arizona.

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* 1. Contact Information

Medical Practice:

Number of providers at your practice that treat adults with diabetes:

Contact Person:

Address:

City/Town:

ZIP/Postal Code:

Website:

Email Address:

Phone Number:

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* 2. Do you know the location of the National Diabetes Prevention Program nearest to your practice? (If you are not certain, please indicate below, or check our website for a list of program locations.)

Yes

Not Certain

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* 3. Are you willing to refer to a National Diabetes Prevention Program?

Yes

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* 4. How many patients per month do you screen for diabetes?

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* 5. Do we have permission to post your practice information (practice name, city/town, and website link) on the Agents of Change website?

Yes