Rewind General Interest Form

1
What's your name? * This field is required.
First Name
Last Name
2
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
3
What is your cell phone number?* This field is required.Your info is private and won't be shared with any third parties.
4
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
5
Your BMI is:
6
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.
7
SC Clinically Prequalified
Yes
No
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
Amputations
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
It looks like you're a good clinical fit for our program! Let's confirm a few more things.* This field is required.
Age
Please Select
Please Select
Yes
No
Live in South Carolina?
13
Rewind clinical costs are covered without copays or coinsurance for most members of BlueCross BlueShield of South Carolina. Do you know what type of insurance you have?* This field is required.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.
BlueCross BlueShield South Carolina (Not Medicare or Medicaid)
Employer / Commercial / Private through other carriers (United, Aetna, etc)
Medicare or Medicare Advantage
Medicaid
Uninsured
I'm not sure
14
SC Payer Prequalified
Yes
No
15
Referrer
16
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