Pre-screening form for A 24-Week, Multicenter, Randomized, Open-Label, Parallel-Group Trial Comparing the Efficacy and Safety of Insulin Glargine 300 U/mL (Gla-300) and Insulin Degludec 100 U/mL (IDeg-100) in Insulin-Naïve People with Type 2 Diabetes Mellitus and Renal Impairment:
Trent LPS17007
Full Name
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First Name
Last Name
Date of Birth
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Month
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Day
Year
Date
Email
example@example.com
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Have you been diagnosed with Type 2 Diabetes Mellitus for at least 1 year?
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Yes
No
When were your most recent blood lab results taken?
*
Within 1 month ago.
Within 3 months ago.
Within 6 months ago.
More than 6 months ago.
What percent was your last HbA1c level at?
*
Check your last lab results.
What are your eGFR(estimated glomerular filtration rate) levels at?
*
Check your last lab results. (You may just enter the number without the units.)
Are you insulin-Naïve? (Meaning you have never been prescribed an insulin injection/insulin analog on a regular basis).
*
Please Select
Yes, I am insulin-Naïve.
No, I am NOT insulin-Naïve.
Form of contact
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Text
Friend Referral
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