Pump Trainer Initial Information

First Name:
Last Name:
Address 1:
City:
State/Province:
Zip Code:
Email Address:
Home Phone:
Business Phone:
Fax:
Title:
CDE?:
 Yes
No
CDM?:
 Yes
No
Other Diabetes Training?:

If selected, do you agree to....

Wear the insulin pump with
saline for at least 7 days?:

 

Yes
No

Check your glucose at
least 4 times a day? :
 Yes
No
Enter your glucose readings, insulin dosing, and
carbs into the glucose monitoring
system during that time? :
 Yes
No
After you are certified will you be
able to train patients for reimbursement? :
 Yes
No
Will you agree to be interviewed
concerning your experiences?:
 Yes
No
Will you be able to speak to patients and other
medical professionals concerning
the benefits of pump training?:
 Yes
No


 



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