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Diabetes Prevention and Control

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A1C Diabetes Registry: "Do Not Contact" Request Form

By submitting this form, you are requesting that (1) you not be contacted, either by letter or phone, regarding your A1C levels through registry-related programs and (2) your provider(s) not receive your A1C information through registry-related programs.
Submitting a "Do Not Contact" request will in no way affect the current care you are receiving or information your provider(s) receives from the laboratory directly. Please note that if your personal information (name, address, or phone number) changes in the future, you need to submit a new request not to be contacted.


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Please ocorrect the following fields:
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Phone
PDF
First Name *
Middle Name
Last Name *
Date of Birth *   mm/dd/yyyy
Address line 1 *
Address line 2 (apt., suite, floor, etc.)
City *
State *
Zip code *
Day Phone
Evening phone
E-mail
Fax number
Check if you are completing this form on behalf of another person.
 
 
 
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