I don't have diabetes, but filled out the info to see if I receive anything in the mail
Personal Information An asterisk (*) designates a required field for enrollment. First Name * Last Name * Date Of Birth / / Address * City * State * Zip *
Phone Number Email Address Type of Insurance - - Select Type Medicaid Medicare Other Insurance I do not have Insurance
Yes, you may contact me by phone in order to complete my enrollment. * This serves as my written consent that a representative from NationsHealth can contact me by phone.
Best time to call: Morning Afternoon Evening Weekends
Yes, I am interested in joining the NationsHealth family. * (Check all that apply) Diabetes Supplies Moist Heating Pads Prescription Medication Ostomy Products Impotence Devices Wound Care Supplies
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