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* Address Line 1:
  Address Line 2:
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* Phone (xxx-xxx-xxxx):
Birthday (mm/dd/yy):
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Preferred place(s) to purchase
supplies to manage your diabetes:
(check all that apply)

 Walmart CVS Walgreens Target
Rite Aid Kroger Meijer SuperValu
Publix
Hypoglycemia Information
* Number of years living with diabetes:
* Type of Diabetes:
* Insulin Dependent:
* Oral Diabetes Medications:
* Average Number of Hypoglycemic
lows experienced per week :
* Preferred Glucose Product:
(check all that apply)		 Tablets Liquid Gel Other
* Favorite flavor(s) of glucose:
(check all that apply)		 Natural Orange Orange Grape
Watermelon Tropical Fruit Assorted Fruit
Raspberry Wild Berry Glucose Bits
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