Diabetes Self-Management Training Patient Name* Patient Name* Patient date of birth* MM slash DD slash YYYY Are you an existing Mini Pharmacy Patient? YES NO *Have you been diagnosed with Diabetes?* YES NO What type of Diabetes?* TYPE 1 TYPE 2 GESTATIONAL Health plan name* *What is your Primary Care Physician (PCP) or Endocrinologist name?* *What is you PCP or Endocrinologist phone number?* *Best cell phone number to reach you:* By Checking this box, I am authorizing Mini Pharmacy and its partner to contact my insurance plan and doctor's office on my behalf in order to facilitate obtaining a continuous glucose monitoring (CGM) system. I understand the Mini Pharmacy or theirs partner may contact me via phone, automated technology, text email, and/or mail using the information I provided above:* Yes I acknowledged No do not use Δ
