For patients to upgrade to Control-IQ™ technology, this form needs to be completed and submitted by their Healthcare Professional
By selecting these checkboxes, I confirm my understanding and acceptance of the following
NZMS Diabetes is committed to protecting and respecting you and your patient's privacy, and we’ll only use personal information to provide the products and services you or your patient requested from us. From time to time, we would like to contact you or your patient about our products and services, as well as other content that may be of interest. If you consent to us contacting you and your patient for this purpose, please tick below:
Patient agrees to receive communications from NZMS Marketing.
In order to provide you or your patient the content requested, we need to store and process personal data. If you consent to us storing you and your patient's personal data for this purpose, please tick the checkbox below.
Patient agrees to allow NZMS to store and process my personal data.
You or your patient may unsubscribe from these communications at any time. For more information on how to unsubscribe, our privacy practices, and how we are committed to protecting and respecting your privacy, please review our Privacy Policy.