American Diabetes Association: Survey

Personal Information


*	First Name: Required
*	Last Name: Required
*	E-mail: Required
*	City: Required
*	State / Province: Required
*	Zip / Postal Code: Required
*	Country: Required
*	Phone Number: Required
	Yes, I would like to receive e-mail from American Diabetes Association

Question - Not Required - Tell us about your story. If you have accompanying pictures, please email the files to eyehealth@diabetes.org or provide us with the URL.

(Maximum response 255 chars, approx. 5 rows of text)

If you are interested in having your most used social media handle tagged when your story is shared, please answer the following questions:

Question - Not Required - What social media platform do you use?

Question - Not Required - What is your social media handle?

Question - Not Required - As a resident of countries affected by GDPR, we are required to request your consent and acknowledgement that you authorize us to store your data by checking this box.

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