Diabetes Self-Management Education (DSME) Session Sign Up Form
Please complete this form if you're interested in participating in our Teach Me Diabetes Program, a diabetes self-management education program (DSME). After you complete and submit this form, our diabetes educator will reach out to you soon and will provide you more information regarding the program including upcoming sessions. If you have any questions, please contact us at (808)-832-8257 or teachmediabetes@times-supermarket.com.
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Alt Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Best way to contact you?
Phone
Email
Is this form being completed by the person living with diabetes?
*
Yes
No (This form is being completed by a physician, family member, caregiver, etc.)
Have you had diabetes education before?
*
Yes
No
Do you have any food allergies?
*
Yes
No
If you answered 'yes' to the question above, please describe your food allergies.
Please tell us what you are allergic to and the type of reaction you have experienced.
What health insurance do you currently have? (Please select all that apply)
*
Medicare
HMSA
UHA
HMAA
HMA
Other
What type of diabetes education are you interested in receiving?
*
1-on-1 education with diabetes educator
1-on-1 education and group/small class education
Group/small class education only
Submit
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