Diabetic Education Class Registration
Please fill out the following information to register for one or more diabetic education (DSMES) classes.
Your Name
*
First Name
Last Name
Date of Birth (MM/DD/YYYY)
*
Email Address
*
example@example.com
Contact Number
*
Please enter a valid phone number.
Have you been diagnosed with any of the following conditions?:
*
Type 1 Diabetes
Type 2 Diabetes
Gestational Diabetes
Pre-Diabetes
None of the above
Your Primary Care Provider's Name:
*
Will you have a guest with you?
Yes
No
Guest Name
Mr.
Mrs.
Miss.
Prefix
First Name
Last Name
Email Address
example@example.com
Contact Number
Please enter a valid phone number.
Would you like to be updated about the upcoming events?
Yes
No
Please select the session you would like to attend. All in person sessions will be held at the Lebanon Wilson County Library, located at 108 S Hatton Ave, Lebanon TN, 37087. Virtual class options only available through full enrollment in DSMES program with Gibbs Pharmacy via the HabitNu Platform and will require referral from your primary physician.
*
Diabetes 101 (In Person) July 18th at 1pm
Diabetes 101 (Virtual) July 25th at 5:30pm
Nutrition Knockout (In Person) August 8th 2024 at 1 pm
Nutrition Knockout (Virtual) August 22nd at 5:30pm
Activity and Risk Reduction (Virtual) September 2024 TBD
The Blood Sugar Solution (In Person) October 2024 TBD
The Blood Sugar Solution (Virtual) October 2024 TBD
Navigating the Holidays (In Person) November 2024 TBD
The above classes are part of an educational program that is billable to insurance. By typing your name below, you are agreeing to participate in each class you've signed up for, and agree to provide relevant insurance information and physician's information, and allow Gibbs Pharmacy to bill your insurance for these services. You may be responsible for any co-payment associated with these services. The pharmacy will only bill your insurance for educational sessions which you attend. Access to the HabitNu platform and virtual class options requires a referral from your provider. Upon reviewing your submission, a member of our team will reach out to you to confirm your information and enroll you in the platform or provide any additional information needed. For any questions, comments or concerns, please contact the pharmacy at 615-449-3355.
*
Please Type Your Full Name
Please upload a picture of your medical insurance cards, front and back. If you prefer to provide these in person, you may contact Jenny at Gibbs Pharmacy, or bring a copy of the insurance cards to your first class session.
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