| Information in RED is required |
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| First Name |
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| Last Name |
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| Address 1 |
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| Address 2 |
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| City |
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| State |
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| Zip Code |
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| Area Code |
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| Telephone Number |
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| Email address |
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Why do we need this information?
Please note that Cleo® 90 Infusion Sets require a prescription. Because this is a prescription item we need the following information about your physician.
Also please have your doctor complete a prescription form and fax it to
1-800-209-2145
Download Prescription Form[ PDF 57 kb]
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| Physician's Name |
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| Physician's Telephone Number |
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| Physician's Address |
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| Insulin Pump Used |
Deltec Cozmo® Insulin Pump
Animas
Disetronic
Minimed 507/508
Minimed Paradigm
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| How long have you been using your current pump? |
1 year
2 years
3 years
4 years
5 years
6 years
Over 6 years
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| Diabetes |
Diabetes Type 1
Diabetes Type 2
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| Age Range |
18 and under
19 to 54
55 and over
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| Current Therapy |
Oral medication
Injections
Pump
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| Current Infusion Set |
Cleo® 90 infusion set
Comfort™
Inset™
Quick-set®
UltraFlex®
Other
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| Please choose one or more options |
I would like a free sample pack of Cleo® 90 infusion sets (Limit one sample per qualified and approved request. Offer valid in the Unites States only. Prescription required - download PDF here)
Send me information on the Cleo® 90 infusion set
Have a representative contact me
Send me information on the CozMore® insulin technology system
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| How did you find out about the Free Samples? |
Recieved a direct mailer with DVD
Healthcare provider/clinic
Diabetes Educator
Magazine Ad
Tradeshow
Google
Yahoo
MSN
Browsing the web
CleoInfusionSets.com
CozMore.com
Other
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| Comments/Questions |
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| Email confirmation |
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