Diabetes Text Messaging Enrollment Form
YourCare now offers text message reminders
to help you manage your diabetes.
To join the Diabetes Texting Program, please complete this form. All fields are required.
How well are you managing your Diabetes?
I Don't Know
What kind of mobile phone do you have?
Regular phone (No data plan)
Which programs would you like to join?
Sign me up for diabetes educational care messages delivered via text 3X/week.
Sign me up for daily reminders to take my meds and check my sugar level
Message and data rates may apply according to my carrier rate plan. I can unsubscribe anytime by texting STOP. For help, call 844-337-7144 weekdays 8am-4pm or email email@example.com.
I understand that no personal information will be sent via text. Personal information provided in this and other surveys will be kept confidential. However, having care messages sent via text could indicate my condition. Since text messages are not encrypted, it may be possible for other people to see my message content.
This iframe contains the logic required to handle Ajax powered Gravity Forms.