Diabetes Wellness Fair | March 19, 2024
If you’re interested in attending the Diabetes Wellness Fair on Tuesday, March 19, fill out and submit this form. If you indicate that you would like a nurse visit, a representative from the MNPS Health Care Centers will contact you to schedule your 30-minute time slot and help you prepare for your visit. (Note: This is a chance to get up to date on recommended screenings/tests, but it is still vital to keep your regular follow-up visits with your primary care provider.) Individuals who have not been diagnosed with diabetes and family members are welcome to attend the nutrition and fitness sessions.
Full Name
*
First name
Last name
Suffix
How did you hear about this event?
*
Email
At the MNPS Health Care Centers
From a friend
Other
Which part(s) of the Diabetes Wellness Fair are you interested in attending? (Your answer helps us plan, but does not commit you to any activity.)
30-minute private nurse visit (may include A1c check, urine protein test, eye exam, foot exam, vaccinations) - reservation required
Beginner-friendly fitness session (two 30-minute options, drop-ins welcome)
Nutrition session (three 20-minute options, drop-ins welcome)
Other
Birth date:
*
-
Month
-
Day
Year
Date
Have you been diagnosed with diabetes or pre-diabetes?
Yes, pre-diabetes
Yes, diabetes
Neither; I have not yet been diagnosed
Which type of diabetes do you have?
Type 1
Type 2
I don’t know
I have not yet been diagnosed
Do you have a primary care physician (PCP)?
Yes
No
What is your PCP’s name (or practice name)?
Do you have an endocrinologist?
Yes
No
What is your endocrinologist’s name (or practice name)?
Contact preference:
*
Phone
Through my account on the My Health at Vanderbilt patient portal
Phone number:
*
-
Area code
Phone number
Best time to reach me:
*
Click to let us know you're human!
*
Submit
Should be Empty: