Server: Netscape-Communications/1.1 Date: Thursday, 18-Dec-97 20:15:18 GMT Last-modified: Friday, 08-Aug-97 00:28:08 GMT Content-length: 5866 Content-type: text/html InfoPak Request Form
Logo
Home
Navigation
MiniMed Web

If you would like to receive the MiniMed Pump Therapy InfoPak - which includes an EXCITING VIDEO on pump therapy (30 minutes long, stuffed with great interviews with real pump users, detailed workings of the MiniMed 507, and lots on pump therapy) - then FILL OUT and SUBMIT the following information about yourself, or the person with diabetes you intend it for, and we'll rush the InfoPak right to you!


Information About Yourself

   Name: 
Address: 
   City: 
  State: 
    ZIP: 
Day Phone:     
Evening Phone: 
(DeNetta, MiniMed's Customer Information Administrator, will give a call-back to answer any pumping questions you might have. She wears a pump herself and is NOT a sales person.)

Information about the person with diabetes:

Who is this information for?
Yourself
Spouse
Child
Other

If other than yourself, please answer the following questions as they pertain to the person with diabetes.

Who is your diabetes doctor? 
         

Doctor's City & State:

What type of doctor?
General Practitioner
Family Practitioner
Internist
Diabetologist
Endocrinologist
Other
Has the doctor discussed pump therapy with you previously?
Yes
No
Name of your insurance company:
Type of insurance plan:
Traditional
PPO
HMO
Medicare
How many years since diagnosis of IDDM? 
         
How many injections of insulin per day? 
         
How many blood glucose tests per day? 
         
Do you experience:
Frequent highs
Frequent lows
Severe Hypoglycemia

How did you hear about MiniMed?
Diabetes Forecast
Doctor
Friend
Internet
Other

Please enter any questions or comments that you may have:


Home • Company • Pump Therapy • Products • Topics & Tips
InfoPak • What's New • Links • Sales • Search • FeedBack