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Accu-Chek Extra Membership Form


(New Zealand residents only)

I am already an Accu-Chek Extra Member:
Sex
Title:
First Name:
Surname:
Street Address
House / Unit:
Street:
Suburb:
City:
Postcode:
Telephone Home:
Please include area code
Telephone Work:
Please include area code
Telephone mobile:

Email Address:

Date of Birth:
Purchase date DD/MM/YYYY:

Meter Serial Number:
Which type of Diabetes do you have:
What year were you diagnosed?:
Do you use insulin?:
 Yes
Insulin device type:
 Injection Pump
If injection, please state number of injections per day:
 1 - 2
If yes. Which brand of insulin pump do you use?:
How many times a DAY do you test your blood glocose level?
How many days a WEEK do you test your blood glucose level?
 1 2 3 4 5 6
Do you use tablets to control your diabetes?
 Yes No
If yes. Please list which tablets you use for your diabetes:
 

Your Privacy

All information you provide here is kept completely confidential and will be used only by Roche Diagnostics NZ to provide you with the Lifetime Warranty on your Accu-Chek Performa meter and the services of the Accu-Chek Extra support programme. You can cancel these services, and check and change any details we hold about you at any time by calling the Accu-chek Enquiry Line 0800 80 22 99.

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