Country Life End Diabetes Program

1

Full Name* This field is required.

First Name

Last Name

2

Age

3

Your current Hemoglobin A1C

4

Your average fasting blood glucose

6

Please list any current medications with doses. (One per line)* This field is required.

7

Do you take any supplements? If so, please list below. (One per line)* This field is required.

9

Phone Number* This field is required.

10

Email* This field is required.

example@example.com

11

How did you hear about this program?* This field is required.Select all that apply

Country Life Website

Flyer or Poster

Facebook

A Friend or Family Member

Country Life Store Staff

Other

12

Payment* This field is required.

My Bag

1

First Name

Last Name