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Diabetes Self Management Program Registration

1.What type of Diabetes do you have?(Required.)
2.What is your last A1c result?(Required.)
3.How often do you monitor your blood sugars...(Required.)
4.Do you use a continuous glucose monitor?(Required.)
5.Do you use an insulin pump?(Required.)
6.What medications do you use to control your diabetes? (Check all that apply)(Required.)
7.Who supports you the most with your diabetes?(Required.)
8.Which of the items below represent the biggest challenge for you to control your diabetes? (Choose your top 3)(Required.)
Your participation in these group meetings is completely voluntary. If you wish to discontinue attending the meetings, you may do so at any time. There is no obligation on your part to attend the meetings, and any decision you make to participate will have no impact on any medical treatment or plan of care with any provider at Montefiore Nyack Hospital. If you have any questions or concerns you can contact the Department Director at 845-587-1318.

By adding your full name and e-mail below 1. you authorize Montefiore Nyack Hospital to send invitations and meeting materials to your designated e-mail account and 2. you release Montefiore Nyack Hospital and the officers, directors, agents, employees and representatives of Montefiore Nyack Hospital from any and all liability which may arise from your participation in the Diabetes Self-Management Education Program, and/or from the information provided to you concerning such program, and/or from any other information provided by you to Montefiore Nyack Hospital.
9.Please enter your full name and contact information below.(Required.)