Rewind General Interest Form

1
To start, let us know what state you live in to confirm if Rewind is available in your area.Rewind is currently available in Michigan and South Carolina.
Please Select
Please Select
Michigan
South Carolina
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
IllinoisIndiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
2
What's your name?* This field is required.
First Name
Last Name
3
What's the best email?* This field is required.Your info is private and won't be shared with any third parties.
example@example.com
4
What is your cell phone number?* This field is required.Your info is private and won't be shared with any third parties.
5
Let's start with finding out the health outcomes Rewind could help you achieve. What's your current weight and height?* This field is required.
Weight (lbs)
Feet
Inches
6
Your BMI is:
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Based on our clinical research, within 12 weeks of starting the Rewind program, you could lose this much weight (in lbs) below. Next, we'll check if there are other outcomes you could achieve.
8
Rewind helps people go beyond weight loss to reversing chronic disease. Please select any diagnosis that applies to you.* This field is required.Your information is private and secure.
Type 2 Diabetes
Prediabetes
Obesity
None
9
Most Rewind members are able to reduce one or more medications. Are you currently taking any diabetes, high blood pressure or weight loss meds?* This field is required.
Yes
No
10
Based on your information and our clinical research, the Rewind program could help you reach one or all of these health outcomes. Which would you feel motivated to achieve?
11
Do any of the following apply to you? These help us determine if our program is a good clinical fit. If you're unsure, it's ok to choose "none" and we'll confirm later.* This field is required.Your info is private and secure.
None
Major complications related to diabetes such as moderate to severe proliferative retinopathy or kidney disease (stage 4 or beyond)
Pregnant/breastfeeding (or planning to be while in the program)
Prior bariatric weight loss surgery
Type 1 diabetes
Active cancer (other than minor skin cancers)
AIDS
Undergoing dialysis
Current nicotine use (or recent changes in smoking habits within last 6 months)
Substance abuse disorder or sobriety
Psychiatric disorder such as schizophrenia or bipolar disorder
Diagnosed eating disorder such as bulimia or anorexia nervosa
12
What is your age?
13
MI Clinically Prequalified
Yes
No
14
Rewind clinical costs are covered without copays or coinsurance for most people with commercial insurance. Do you know what type of insurance you have?If you're not sure, that's ok. You can either upload a photo of your insurance card next or we can confirm on the phone later.
Employer / Commercial / State Health Plan through BlueCross BlueShield
Employer / Commercial through other carriers (United, Aetna, etc)
Medicare or Medicare Advantage
Medicaid
Uninsured
I'm not sure
15
MI Insurance Prequalified
Yes
No
16
How did you hear about Rewind?
Event
Facebook
One of our ambassadors
Doctor referral
Radio
Instagram
Friend or Family Member
TV
Other
17
Referrer
18
Should be Empty: