FREE Patient Education Kits
for Diabetes Care Professionals

Please Note: Contents of
the kits change from
time to time, and specific
items may differ from those
depicted in the photo.

Please complete and submit this form if you would like to apply for the FREE Diabetes Outlook® patient education kit program. All information must be completed in order for you to qualify. Kit quantities are limited, and all applications will be individually reviewed for eligibility. Only diabetes care providers based in the continental United States qualify for this program.

Hint: Use your “tab” key or mouse pointer to move to each field.
Do not press your “enter” or “return” key,
because that will submit a blank form.

Learn More About Diabetes Outlook

1. Who should we contact at your location concerning administration of the program?
(Note: Kits will be shipped to the attention of the main contact person. Please do not use commas
when typing this information.)

Main Contact:	Name Job Title
Alternate Contact:	Name Job Title

2. Practice/Facility Phone Number? (with area code)

3. What is your shipping address?  (Note: Type your shipping address exactly as you would like
     it to appear on the shipping label -- there are a maximum of 35 characters per line. Please do
     not use commas in your address. P.O. Boxes are not allowed for kit shipments.)

Our shipping address is:

Practice/Facility Name
Dept Name (if applicable)
Street
City
State
Zip Code

4. What is your mailing address?

mailing & shipping address are identical (as listed above)

Practice/Facility Name
Dept Name (if applicable)
Street
City
State
Zip Code

5. Email address (Used ONLY for important communications about our program.)

6. Fax number (with area code)

7. Please indicate how many new patients enter your program in an average month.

new patients per month

8. Are there any types of product samples you find objectionable, which would
cause you to reject the program?

	All generally acceptable
	Diabetes Drink (e.g. Splenda Diabetes Care Shake)
	OTC Meds/Vitamins
	Other (please specify)

9. How did you hear about this program? (Check all that apply)

	Received info in the mail
	Magazine/professional journal ad or listing
	Email
	Internet listing
	Friend/colleague referral
	AADE Web Site
	AADE conference
	Other professional conference (please specify)
	Other (please specify)

10. Approximately how many patient education kits would you like to receive per year?
(Note: Shipments will be made once per year.)

requested patient kits per year

11. Does your Practice/Facility have a storage problem? (Note: Usually there are 30-60 kits
per carton, depending on the weight of the kits.)

	NO
	YES ... If YES, we can only accept cartons per shipment. (Cartons are approximately the size of a large microwave oven box; as large as: 23" long x 15" deep x 15" tall.)

12. Please indicate whether you are a:

Diabetes Educator

Dietitian

Doctor's Office

	What specialty?
	Number of doctors at this location

Other (please specify)

13. What are your professional credentials? (check all that apply)

	BS/BSN
	LPN
	MSN
	RD
	CDE
	MD
	NP
	RN
Other:

OPTIONAL: If you have any questions, comments, or special
instructions, please note those here:

We / I would like to receive the free Diabetes Outlook® Program.
We / I agree to distribute only one patient kit per diabetes patient.

Your Name
Job Title

KIT QUANTITIES ARE LIMITED, therefore all applications will be screened to
determine whether they meet eligibility criteria. The Dialogue Company reserves the
right to limit distribution quantities, and remove any facility from the
program that it deems necessary.

Diabetes Outlook® Program
The Dialogue Company
106 Straube Center Blvd.
Pennington, NJ 08534

Fax: (609) 737-6927
Phone: (800) 972-7994
Email: programs@adialogue.com

FREE Patient Education Kits for Diabetes Care Professionals

FREE Patient Education Kits
for Diabetes Care Professionals