T1D Screening Queen
Please complete the form to register for screening and prepare your information.
What would you like?
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Sign up to attend an upcoming social event
Get screened in office
Register to get screened at an event
Personal Information
First Name
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Last Name
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Date of Birth
*
-
Month
-
Day
Year
Date
Email Address
*
example@example.com
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Medical History
Do you have a family history of Type 1 Diabetes?
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Yes
No
Not Sure
Have you ever been previously diagnosed with Type 1 Diabetes?
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Yes
No
Do you or your family have a history of autoimmune disease, Hashimoto's, Graves, or celiac disease?
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Yes
No
Do you have a personal history of gestational diabetes?
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Yes
No
Have you ever been told you are "borderline" or have pre-diabetes?
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Yes
No
Have you ever been told your glucose levels were elevated?
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Yes
No
Logistics & Consent
Are you available to come to a screening location in Boca Raton, Miami, or Fort Lauderdale Florida?
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Boca Raton
Miami
Fort Lauderdale
Any
Neither
How Did You Hear About Us?
Select All That Apply
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Facebook
Instagram
Tiktok
LinkedIn
Google Search
Community Event
Referred by a Friend/Family Member
Recommended by Doctor/Provider
Other
Submit Registration
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