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  • Diabetes Prevention Program (Enrollment)

    Please complete the following questions to enroll in one of our class. The information requested will be used to help better understand your needs in the class. Some of the information is required to be collected by the CDC diabetes prevention program.

  • Class Selection

    Group classes are held at the same day and time for the program duration. The classes are for 1 hour and begin weekly for the first 12 sessions, and then gradually moves out to monthly as the program progresses.
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  • Insurance

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  • Medicare Beneficiaries

    Please provide the number on your red, white, and blue Medicare card.

  • Commercial Insurance or Medicaid

  • Screening Questions

    Please complete the following questions.
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  • Consent to Participate

    I have read, or have had read to me, the written information regarding the Diabetes Prevention Program. I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless Hartzell's Pharmacy, its subsidiaries, divisions, affiliates, agents, officers, directors, contractors, and employees from any and all claims arising out of, in connection with, or in any way related to the participation in this program. I have read and reviewed the Notice of Privacy Practices available at www.hartzells.com.
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  • Pharmacy Use Only

    Do no complete the below questions
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