New Patient Enrollment
Diabetes Educational Classes
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Sex
Please Select
Male
Female
Non-Binary
Transgender Male
Transgender Female
Prefer Not to Say
Other
Other:
Height (inches)
Weight (pounds)
Marital Status
Please Select
Single
Married
Divorced
Legally separated
Widowed
Contact Number:
E-mail
example@example.com
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Class Selection
Which program are you registering for?
Diabetes Prevention Program (Patients that have a diagnoses of pre-diabetes)
Diabetes Self- Management Program(Patients that have a diagnoses of Diabetes)
Preferred Class Format
In-Person
Virtual
No preference
Health Information
Have you been diagnosed with diabetes?
Yes
No
If yes, what type of diabetes do you have?
Type I
Type II
Gestational diabetes
Other
Please list it here:
Do you have any dietary restrictions or allergies?
Yes
No
Please list it here:
How did you hear about the program?
Doctor/Healthcare Provider Referral
Family/Friends
Website
Social Media
Other
Please list other here:
Do you have any specific goals for attending this program
Weight Management
Blood Sugar Control
Healthy Eating
Physical Activity
Other
Please list other here:
Taking any medications, currently?
Yes
No
Please list it here
In case of emergency
Emergency Contact:
First Name
Last Name
Relationship
Contact Number
Additional Information
Are you a G. A. Carmichael Family Health Center (GACFHC) Patient?
Yes
No
GACFHC Provider Referred
Consent to Participate:
I consent to participate in the Diabetes Prevention and/or Self Management Program and I understand that my information will be used to provide data and support during the program
Permission to Contact:
I agree to be contacted via phone, email, or mail regarding program updates and related health information.
Submit
Should be Empty: