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 Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
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?
Phone
Email
Is this form being completed by the person living with diabetes?
*
Yes
No (This form is being completed by a physician, family member, caregiver, etc.)
Have you had diabetes education before?
*
Yes
No
What health insurance do you currently have? (Please select all that apply)
*
Medicare
HMSA
UHA
HMAA
HMA
Other
What type of diabetes education are you interested in receiving?
*
1-on-1 education with diabetes educator
1-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.
*
Morning
(8:00AM-12:00PM)
Afternoon
(12:00PM-4:00PM)
Evening
(4:00PM-6:00PM)
Not available
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
How did you hear about us?
Any Times Pharmacy location
Website
Social Media
Physician/Doctor's Office
Other
Submit
Should be Empty: