Rewind General Interest Form

1
Is MI Campaign Referral
YESNO
2
Hi there! What's your name?
First Name
Last Name
3
What's a good email?
example@example.com
4
What's a good cell phone number?By providing your phone number, you are opting in to receive occasional text messages from Rewind.
5
What's a good cell phone number?By providing your phone number, you are opting in to receive occasional text messages from Rewind.
Area Code
Phone Number
6
What is your age?* This field is required.We are only able to support individuals between ages 18-70
7
Who can we thank for referring you to Rewind?[kate copy here about this will help them get credit blah blah - if they make it to this point they've been
8
Please select any diagnosis that applies to you.* This field is required.Don't worry, your information is always encrypted and secured.
Type 2 Diabetes
Prediabetes
Obesity
None
9
What is your weight?
10
What is your height?
feet
inches
11
What is your Body Mass Index (BMI)?We currently accept people with a BMI between 30-50. Don't know yours? You can use a BMI calculator here
12
Which state are you currently located in?Rewind currently operates in Michigan and South Carolina.
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
13
State Included? If = 1 Yes
14
Do any of the following apply to you?
T2D with major complications 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
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
None
15
Please share the name of the friend or family member who referred you to Rewind.
16
MI Clinically Prequalified Binaryobesity, pre or T2
Yes
No
17
Have you ever been seen at the University of Michigan before for any healthcare?
YESNO
18
SC Clinically Prequalified BinaryTYPE 2 ONLY
Yes
No
19
SC Waitlist Clinically Prequalified BinaryTYPE 2 ONLY
Yes
No
20
For insurance, do you have standard Medicaid or Medicare?We cannot accept traditional Medicaid or Medicare at this time.
YESNO
21
If you have health insurance, please select your carrier.
22
Hidden Insurance
23
SC Payer Qualthis is a hidden field used for logic purposes
Yes
No
24
MI Payer Qualthis is a hidden field used for logic purposes
Yes
No
25
Please confirm your email.Please confirm the below is correct.
example@example.com
26
Please confirm your name.Please confirm the below is correct.
First Name
Last Name
27
How did you hear about Rewind?* This field is required.
Event
Radio
Facebook
Instagram
One of our ambassadors
Friend or Family Member
Doctor referral
TV
Other
28
Is there anything else you would like us to know?* This field is required.
No
Other
Should be Empty: