What type of Diabetes do you have? Please select Type 1 Type 2 Gestational Pre-diabetes

Which of the following methods do you use to manage your diabetes? Please select Insulin Syringe Insulin Pump Insulin Pen Oral Medication (Pills) Other None

How often do you test your blood glucose levels? Please select 1 or 2 times per day 3 or 4 times per day More than 4 times per day I do not test my blood for glucose

What Type of Insurance or reimbursement do you have for your test strips? Please select Private Insurance or Managed Care Plan Medicare Medicare plus other coverage Medicaid No Coverage Other

Would you like to receive promotional offers and diabetes information from Nova Diabetes Care? Please select Yes No