FREE Diabetes Management Interest Form

Thank you for your interest in the Community Diabetes Care Program at CVS Pharmacy in East Point!

Please answer 5 questions to learn more about a FREE health screening at CVS Pharmacy (2907 Main Street) and FREE diabetes supplies and online education.

We look forward to hearing from you!

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* 1. What is your First and Last name?

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* 2. Cell phone number:

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* 3. Email:

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* 4. How did you hear about the health screening event?

Tri-Cities High School Ambassador (be sure to answer #5)

CVS Pharmacist or staff member

CVS flyer or ad

Facebook

Diabetes class

Healthcare professional

Friend or family member

Other (please specify)

FREE Diabetes Management Interest Form

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* 1. What is your First and Last name?

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* 2. Cell phone number:

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* 3. Email:

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* 4. How did you hear about the health screening event?

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* 5. If applicable: Please enter the name of the TCHS Ambassador who referred you:

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* 6. Any other comments or questions?