Screener

Eligibility Screener

Name *

First

Last

Email *

Phone Number *

-

Zip/Postal Code *

Are you 30 years of age or older? *

Yes No

Do you have type 1 diabetes? *

Yes No

Do you have type 2 diabetes? *

Yes No Unsure

Have you suffered from a heart attack or chest pain that required hospitilization within the past 6 months? *

Yes No

Do you use Byetta® , Januvia®, or other incretin-based agents? *

Yes No Unsure

Submit

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