Forms for DCC Programs

Pump/CGM Registration Form

This form is personal information about you if you are being seen for insulin pump or continuous glucose monitoring training.  Please fill this out and bring with you to your first session.   This information is confidential and protected.
Pump Registration Form.pdf

General Registration Form

This form is personal information about you that we will use to create a file for you.  Please fill this out prior to your first session with us.  This information is confidential and will be protected.
General Registration Form.pdf

Prediabetes Registration Form

Personal information and questionnaire for registration in the prediabetes program. z
Prediabetes Registration Form.pdf

Privacy Policy

Describes how the Diabetes Community Center uses and discloses your personal health information as allowed by the Health Insurance Portability and Accountability Act (HIPAA).
Privacy Policy.pdf

Insulin Pump Evaluation and Training

Information to help you evaluate whether or not you are ready to start on insulin pump therapy.  This form also explains what to expect at each of the sessions with us.
New Pump Start Eval.pdf

Insulin Pump Upgrade Form

Summary of the training required when upgrading your insulin pump and what to expect in each session.
Pump Upgrade Form.pdf

3-Day Blood Glucose Log

This form is for you to log your carbs and blood glucose levels each day for a 3-day period.  Please print this, fill it out,  and bring to your first appointment.  You can make as many copies of this form as you need to!
3-Day BG Log.pdf

7-Day Blood Glucose Log

This form is for you to use to log your carbs and blood glucose levels over a 7-day period.  Please print this and bring it to your appointment.  You can make as many copies of this log as you need!
7-Day BG Log.pdf

Insulin Pump Pointers

This form gives you insulin pump tips and reminders for insulin pump users, including hypoglycemia and DKA protocols.   It is especially helpful for new pump users.
Pump Pointers.pdf

Personal Pump Settings Evaluations

This form gives you the formulas you need to test and evaluate your basals, insulin-to-carb ratios, and correction factors.
Pump Settings Eval.pdf

 


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