Diabetes Self-Management Education Registration Form

I am interested in learning more about managing my Diabetes.

Medicare Part B Information

Please provide your Medicare Part B information (red, white, and blue card)

Medicare Part B number

Medicare Part B start date

Please enter the date in the format MM/DD/YYYY

Colorado Medicaid Information

Please provide the information from your CO medicaid card

CO medicaid number

Letter + six numbers

Insurance Card Information

Please provide the information from your insurance card

BIN

PCN

ID Number

Group number

Patient Name

First Name

Middle Name

Last Name

Date of Birth

Age

Gender

Race / Ethnicity

Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Patient Phone Number

Enter your phone number in the format: (000) 000-0000

Email Address

Primary Care Provider (PCP) Name

First Name

Last Name

Primary Care Provider (PCP) Phone Number

Enter phone number in the format: (000) 000-0000

Reason to sign up for DSME

Please List Current Medications and/or Supplements You Are Taking

Which of the conditions below describe your health?

How often do you check your blood sugars?

What times of day do you usually check your blood sugars?

What goals do you have regarding your diabetes management?

What would you like to know more about diabetes?

Is there anyone who assists you with managing your diabetes?

When would be the best times for you to meet?

Consent to Initial Consultation

Form completed by

First Name

Last Name

Representative name (if applicable)

First Name

Last Name

By checking this box, I give my informed consent to the collection, storage, and processing of my personal data and health data as described in the Privacy Policy and Notice of Privacy Practices. I understand that I can withdraw my consent at any time.

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Salida Pharmacy and Fountain

We're a locally-owned community pharmacy dedicated to providing outstanding customer service at an affordable price. A one-stop shop for all your pharmacy and medical needs. At Salida Pharmacy & Fountain, you can count on personal attention provided by our caring, professional staff. Visit us today and experience the Salida Pharmacy & Fountain difference.

Find us

137 F Street, Salida, Colorado 81201, United States

Contact us

719-530-4790

info@salidapf.com

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