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English (US)
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.
Which class would you like to enroll in? (In person classes held at Hartzell's Pharmacy)
Virtual Option - We will contact you to find a date/time
In Person - We will contact you to find a date/time
Not sure yet
Patient Name
*
First Name
Last Name
Suffix
Date of Birth
*
-
Month
-
Day
Year
Date - Moderna and J&J 18+; Pfizer is 12+
Sex
*
Male
Female
Gender
*
Male
Female
Transgender
Home Phone Number
*
Cell Phone Number
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Email
example@example.com
Race:
*
Not Specified
Asian
American Indian or Alaska Native
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other
Ethnicity:
Hispanic or Latino
Not Hispanic or Latino
Unknown
What is the highest level of education you completed?
*
Less than grade 12 (no high school diploma GED)
Grade 12 or GED
Some college or technical school
College or technical school graduate or higher
Primary Care Provider (PCP) Name
First Name
Last Name
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Insurance
Do you currently have health insurance (commercial coverage, Medicaid, Medicare, etc)?
*
Yes - please complete information below
No - by choosing no you attest that you DO NOT have current coverage.
Who is the primary payor for your participation the Diabetes Prevention Program?
*
Medicare
Medicaid
Private Insurer
Self Pay
Dual Eligible (Medicare and Medicaid)
Employer
Social Security Number
Used for insurance verification and/or billing
Please upload a photo of your MEDICAL insurance card here. Front and back of card is needed.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
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Medicare Beneficiaries
Please provide the number on your red, white, and blue Medicare card.
Medicare Number
Medicare Number (MBI) has 11 alphanumeric characters and can be found on your Red, White, and Blue Medicare Card.
Commercial Insurance or Medicaid
Health Insurance Plan
Medical Insurance ID
Medical Group Number
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Screening Questions
Please complete the following questions.
What motivated you to sign up for the program? What was the most influential factor?
*
Health care professional
Blood test results
Prediabetes risk test
Someone at a community based organization (church, community or fitness center, etc)
Family or Friends
Current or past participant in the national DPP LCP
Employer or employer's wellness plan
Health insurance plan
Media advertisements
Did a healthcare professional encourage you to join this DPP course?
*
Yes, a doctor/doctor's office
Yes, a pharmacist
Yes, other health care professional
No
Have you been diagnosed with Prediabetes?
*
Yes, I have had bloodwork indicating that I have prediabetes.
Yes, I have prediabetes, but it has NOT been diagnosed with blood glucose testing.
No, I do not have prediabetes
Is your Prediabetes diagnosed by the Prediabetes Risk Test?
*
I have determined that I have Prediabetes by taking the Prediabetes Risk Test
I have a diagnosis of Prediabetes from bloodwork, not from the prediabetes risk test.
I do not have prediabetes
For females only: Did you have Gestational Diabetes during pregnancy?
Yes, I had been diagnosed with Gestational Diabetes during a past pregnancy
No, I have never been diagnosed with Gestational Diabetes during pregnancy
What is your age?
*
What is your most recent A1C (%) from your bloodwork?
What is the date of your A1C reading?
-
Month
-
Day
Year
Date
What is your height? (inches)
inches
Do you have a scale at home to check your own weight?
*
Yes, I have a scale at home
No, I do not have a scale at home
What is your weight today?
pounds (lbs)
BMI Calculator: Please enter your weight and height.
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.
Printed Name
*
Printed name of individual signing this form
Signature of Person Enrolling in class
Clear
Today's Date
-
Month
-
Day
Year
Date
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Pharmacy Use Only
Do no complete the below questions
Cohort ID
Participant ID
Coach ID
Clinic notes (optional)
Should be Empty:
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