Diabetes Insulin Assistance Program A partnership of Metro Health and H-E-B

Diabetes Insulin Assistance Program

A partnership of Metro Health and H-E-B
Name:*
Phone*
Please enter a valid phone number.
Do you have type 1 or type 2 diabetes?

Type 1Type 2
How confident do you feel in managing your diabetes and taking care of your health?

Not Confident/UnsureSomewhat ConfidentConfidentVery Confident
Race:*

American Indian/Alaska NativeAsianBlack/African AmericanNative/Hawaiian/Other Pacific IslanderWhiteOtherPrefer not to disclose
Ethnicity:*

HispanicNon-HispanicPrefer not to disclose
Consent to share information with the City of San Antonio

I am participating in the City of San Antonio’s Insulin Support Program administered by H-E-B Pharmacy. I certify that I am at least 18years of age and have the right to contract in my own name. I agree to share my name, phone number, and race/ethnicity listed below with the City of San Antonio. I understand that City of San Antonio will use this information to contact me about free resources and to gain a better understanding about the needs of the community. I understand that all data will be kept confidential, in accordance with the Health Insurance Portability and Accountability Act (HIPAA).
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I have read and acknowledge the information above. By submitting this form, I am providing my electronic consent to sharing my information listed above. *
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