Type 2 Diabetes Patients

1
Name* This field is required
First Name
Last Name
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2
Email* This field is required
example@example.com
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3
Phone Number* This field is required
Area Code
Phone Number
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4
CITY and STATE
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5
What is your current occupation?
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6
Based on the info you received about this project so far, please tell us why you'd be a good fit for this! For instance, if you are an Architect/Designer or in a Travel-related field, please tell us about your work. If you are a frequent traveler or Design enthusiast, tell us where you've been or more about your interest. These spots will be documentary style portraits, so please include details.* This field is required
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7
Please tell a bit about your self (passions, interests, hobbies).
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8
Please provide any links to your social media accounts.
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9
MEDICAL CONDITIONS

Subject to your agreement to the waiver below, please share information regarding any medical conditions that you may have and are comfortable discussing publicly for potential projects. You acknowledge and understand that your personal health information may be protected from disclosure by the Health Insurance Portability and Accountability Act ("HIPAA") and other privacy laws. By selecting, "I agree" below, you knowingly waiving your rights under HIPPA and any other provacy laws and consent to PINCH HITTER PROJECTS electronically storing the personal health information that you disclose via this form and reviewing it for purposes of contacting you about future projects for which you may be qualified for based on your responses.
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10
By selecting one of the options below, you acknowledge that you have read and understand the above statement:* This field is required
I agree to waive my rights under HIPAA and any other privacy laws and permit PINCH HITTER PROJECTS to store and access my personal health information for purposes of contacting me for projects.
I decline to provide my personal health information.
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11
Which option best describes your current diagnosis?* This field is required
Type 1 Diabetes
Type 2 Diabetes
Pre-Diabetic
I do not have Diabetes.
Type 3 Diabetes
Other
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12
How long have you had Type 2 Diabetes?* This field is required
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13
Do you currently use an injectable to treat your Diabetes?* This field is required
YESNO
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14
Please list which medication(s) you currently take for your condition.* This field is required
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15
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16
Ethnicity
African-American/Black/Carribean
Hispanic/Latinx/Chicano
Asian
Caucasian/White
Other
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17
Age-range* This field is required
Under 35
36 to 40
41 to 60
61+
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18
How did you hear about this project?* This field is required
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19
Please submit a recent photo of yourself.
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