Times Pharmacy DSME Program Request Form

Diabetes Self-Management Education Request Form
Please complete this form if you're interested in participating in our Teach Me Diabetes Program, a diabetes self-management education program. After you complete and submit this form, our diabetes educator will reach out to you soon and will provide you more information regarding the program. If you have any questions, please contact us at (808)-832-8265.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Phone Number*
Please enter a valid phone number.
Alt Phone Number
Please enter a valid phone number.
Email
example@example.com
Best way to contact you?

PhoneEmail
Is this form being completed by the person living with diabetes?*

YesNo (This form is being completed by a physician, family member, caregiver, etc.)
Have you had diabetes education before?*

YesNo
What health insurance do you currently have? (Please select all that apply)*

MedicareHMSAUHAHMAAHMAOther
What type of diabetes education are you interested in receiving?*

1-on-1 education with diabetes educator1-on-1 education and group/small class education

Please select all dates and times you are most available for 1-on-1 and/or group diabetes education classes.*

How did you hear about us?

Any Times Pharmacy locationWebsiteSocial MediaPhysician/Doctor's OfficeOther
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Diabetes Self-Management Education Request Form