DO NOT CONTACT DDA BY TELEPHONE. YOU WILL BE PUT ON A WAITING LIST FOR THE SUPPLIES AND/OR ADVOCACY YOU NEED IF WE DO NOT HAVE THEM IMMEDIATELY AVAILABLE. YOU CAN GET A FREE E-MAIL ADDRESS AND HELP USING E-MAIL VIA YOUR LOCAL PUBLIC LIBRARY.
DIABETES SUPPLIES HELP FORM
What is your name?
What is your email address?
Address:
city:
country:
zip/mailing code:
telephone:
fax:
DO NOT CONTACT DDA BY TELEPHONE. YOU WILL BE PUT ON A WAITING LIST FOR THE SUPPLIES AND/OR ADVOCACY YOU NEED IF WE DO NOT HAVE THEM IMMEDIATELY AVAILABLE. YOU CAN GET A FREE E-MAIL ADDRESS AND HELP USING E-MAIL VIA YOUR LOCAL PUBLIC LIBRARY.
Info about you, e.g.your problem, disability and other: communication/response:
Diabetes supplies needed and/or Information Required/Requested:
Is this comuunciation urgent? Yes
No
Date response needed by: DAY:
MONTH:
YEAR:
