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Accu-Chek Spirit Information Request
To request a pack, complete the details requested and submit the form to us:
*
Title
Mr
Mrs
Miss
Dr
*
First Name
*
Surname
*
Address Line 1
Address Line 2
*
City
*
Postcode
Tel No
*
Email
Meter Name (If applicable)
Serial Number (on back of meter) (If applicable)
About your diabetes:
Which best describes your diabetes?
Type 1
Type 2
Other
What type of therapy do you follow?
Insulin
Insulin & Tablets
Tablets
Tablets & Diet
Diet
Insulin Pump
How often do you test your blood glucose?
Once a week
More than once a week
Once a day
2-3 times a day
4-5 times a day
6+ times a day
With regards to the management of your diabetes who do you see most often?
Diabetes Specialist Nurse
GP
Practice Nurse
Other
Please tick the box if you would like to receive diabetes related information from us
Email
Post
I agree to Roche Diagnostics Ltd and its appointed agents using the information I have provided in this form for the provision of their services to me.
Roche Diagnostics Ltd. abides by the Data Protection Act 1998 and is registered as a data controller under this Act. Any information provided by you will not be disclosed to any third parties except to our appointed agent.
Last modified: 15/08/2008
