To become a member of the FreeStyle Promise™ Program, please enter the information requested below.   First Name   required   Last Name   required   Address   required    City   required   State <--Select--> AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WI WY WV   required   Zip Code   required   Home Phone Number  required   Confirm Phone Number  required   E-mail Address  required   Date of Birth MM Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec  /  DD 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31  /  YYYY 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909  required How long have you used your current meter? -- Select -- Less than 3 months 3-6 months 7-12 months More than 12 months   required   Date of Diabetes Diagnosis -- Month -- Jan Feb Mar April May June July Aug Sept Oct Nov Dec    -- Year -- 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900 required   Which type of diabetes do you have? -- Select -- Type 1 Type 2 Gestational   required   How many times do you test your blood glucose? -- Select -- 1 per day 2 per day 3 per day 4 or more Do not test daily   required   Do you use insulin to manage your diabetes?  required Yes No   What methods do you use to manage your diabetes?  required Insulin syringe (shot) Insulin pump Insulin pen   What type of insurance do you have? -- Select -- Medicare Medicaid Private Insurance No insurance Other government insurance   required By clicking on the "Submit" button, I agree that: (1) the information I've provided will be used only by Abbott Diabetes Care/Abbott Nutrition and its contracted third parties to mail, telephone, and email me helpful information on diabetes and related treatments, products and services, and for marketing and informational purposes, (2) Abbott Diabetes Care will not sell or transfer my name or contact information to any third party for its marketing use, (3) I may be removed from Abbott Diabetes Care's mailing list or request a copy of this information by contacting 888-522-5226, and (4) if I am a CA resident, this consent shall remain valid for five years from the date of the signature on the California Resident Consent Form. California Resident Under California state laws, we are required to obtain written permission from all California residents to formally establish a communication relationship. If you are a permanent California resident and would like to receive information from Abbott Diabetes Care/Abbott Nutrition, please confirm by signing the consent authorization form below. You will not receive additional information from us unless you have fully completed and mailed in this consent form. Download California Resident Consent Form   Yes, I wish to receive diabetes information or promotional offers from Abbott Diabetes Care/Abbott Nutrition. In the event this form is incomplete or filled out incorrectly, Abbott Diabetes Care Inc. may contact you for further clarification. † Legal notice: 1. Void where prohibited by law. The co-pay savings offer is not valid for persons eligible for reimbursement of blood glucose test strips, in whole or in part, under Medicare, Medicaid, or similar Federal or State Programs. In Massachusetts, the co-pay savings and free meter offer is not valid for persons eligible for reimbursement of this product, in whole or in part, by an insurance company or other third-party payer. 2. One card per person. You may not combine this offer with any other offer. 3. Abbott has the right to rescind, revoke, or amend this offer without notice. ‡The information provided by the team of Diabetes Educators is for general background purposes and is not intended as a substitute for medical diagnosis or treatment by a trained professional. You should always consult your physician about any health care questions you may have, especially before trying a new medication, diet, fitness program, or approach to health care issues. DOC20014_Rev-A 08/09