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Fill out the form and get a coupon for a New Diabetic Meter.
We pride ourselves on first-class customer service, giving you and your loved ones the personal attention you deserve. Our staff has over 40 years of health care experience. Just fill out the form and you'll receive a coupon redeemable for a New Meter at little or no cost to you, with your first order of supplies from Doctor Diabetic.
PLEASE COMPLETE THE FORM BELOW.
ALL INFORMATION MUST BE 100% ACCURATE FOR US TO FULFILL YOUR REQUEST.
Sorry, No Medicare Advantage or HMOs.
Have you or someone you love been diagnosed with Diabetes?
Is the Diabetic covered by Medicare insurance?
Date of Birth:
Day Time Phone:
Best Time to Call:

Do you have diabetes?
Yes No
Only fill out this form if you wish to be contacted with a quote. Filling out this form does not affect your chances of winning.

If you are healthy and over 24, get 5 free quotes from the nation's top health insurance companies.

One Stop Health Quotes offers a full range of health insurance quotes for healthy individuals and families over 24 years of age. Our wide selection of reputable and trusted insurance companies* is unsurpassed in the industry. (not available in NY, NJ, MN, WA)

Would you like a specific quote?
Date of Birth:
Gender:
Are you self-employed?
Yes No

Have you or anyone requesting insurance ever been diagnosed with:

Asthma and/or High Blood Pressure (HBP)?
Any other pre-existing conditions which might affect your premium?
Yes No
(i.e. Diabetes, Depression, Cancer, Heart Conditions, HIV, Stroke, etc.)
Is anyone requesting coverage currently pregnant?
Yes No
Is anyone requesting insurance taking prescription medications?
Yes No
(excluding voluntary meds such as birth control, Viagra®, allergy)


Complete Contact Information below ONLY if you wish to receive a health Insurance quote: (you will be contacted by phone with your quote )

Total Household Income:
Your Height & Weight: lbs.
Day Time Phone: ( ) - ext.
Evening Phone: ( ) -
Best Time to Call:

  First Name Last Name Age Gender Relationship
Person 1
Person 2

*One Stop Health Quotes is referral service helping you find the most competitive insurance rates available. We have helped thousands of consumers save money on their insurance.

One Stop Health Quotes is not an insurance company or agent and does not provide insurance quotes to the consumer. Insurance quotes are provided by licensed insurance professionals who are members of our network.

Specific Limitations and exclusions apply. All information for health insurance must be confirmed by the health carrier before issuing policy. In some states, and for some medical conditions, coverage may not be available. For those who are unable to receive an insurance quote, or are ineligible, you will be referred to a health savings plan.

In order to take advantage of this offer you should be 25 years of age or older and in good health.
Would you like to win a $ 10,000 Spring Shopping Spree? Enter for a chance to win $ 10,000 and sign up for email sales alerts to get great deals from stores like Wal-Mart, Target, Best Buy and more.
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Are you interested in discounted jewelry up to 95% off?
Yes No

Tired of paying for car repairs?
Yes No
Be in the beauty know! Would you like to receive free periodic emails on sales, events and new product launches from Avon? Plus receive a special offer of Free Shipping when you sign up today!
Yes No

Are you a Diabetic?
Yes No
Vindale Research Would you like to join the finest minds in consumer research and change the world one product at a time? Share your unique opinion and get paid from $5 to $75 for every survey you complete!
Yes No


Protect Your Family With Up To $25,000 In Affordable Life Insurance!

With LifeChoice®: Whole Life Insurance from Colonial Penn you can select from five benefit amounts: $5,000, $10,000, $20,000 and $25,000.
  • No Medical Exam...Ever
  • Rate Guaranteed Not To Go Up...Benefit Guaranteed Not To Go Down.
  • Money-Back Guarantee!
  • It's so easy learn more. There's absolutely no obligation on your part.
Phone:
Date of Birth:
I want Colonial Penn to contact me about their LifeChoice Whole Life Insurance: Yes No Thanks
This offer is available to ages 35-75 in most states. Age limits vary in some states. This offer is not available in ME, MT, NY, VT, or WA. An insurance agent my contact you. Group Policy Form #4-82-839; Individual Policy Form Series 3-82-775. Colonial Penn Life Insurance Company, Philadelphia, PA.
Get Paid to Read Email and Take Surveys Online.
Want to find out how to make money by reading your email or taking surveys online? It's Free and you get a $5 signup bonus just for joining.
Yes No
Graduated owing more than $10,000 in student loans? Reduce your payments by 55% or more! Lower your monthly payments to as little as $100 today - with just one phone call! Let an Atlas Education Finance expert show you how!
Yes No

Would you like to join MyPoints and make every purchase count? Earn Points for shopping and reading email and redeem Points for gift cards from your favorite stores like Target, Home Depot, Wal-Mart and many more?
Yes No
Would you like to join the Nielsen//NetRatings Research Panel and help us chart the course of the Internet of tomorrow? It's free, it's easy, and you could be one of fifty $1,000 winners this quarter!
Yes No
Would you like to receive free product samples, discounts and other exclusive health & wellness offers? Join Healthier.com!
Yes No
Want FREE samples of brand name health products, like Robitussin - Nexium - Advil - and more?
Yes, I authorize to send this information to Healthy Samples and its partners
No
Would you like to learn more about Vacation Ownership? A representative from WorldMark by Wyndham, formerly known as Trendwest Resorts, Inc. or Wyndham Vacation Resorts can contact you to learn more about vacation ownership opportunities in destinations such as Las Vegas, Orlando, Mexico and more. It can pay for itself with one trip!
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Would you like a FREE SurveyClub Membership?
Special Report: Top 25 Survey Sites Free to Members. Make some extra cash and earn great prizes just for doing quick and easy online surveys all in your spare time!
Yes No
Looking to escape completely on a premium Princess Cruise? Register for valuable email newsletters from the SureCruise.com Superstore. In addition to money-saving "flash" deals, be "in the know" with insider cruise news and extraordinary cruise offers.
Yes No

Would you like to earn gifts and rewards from home scanning the products you purchase? Join ACNielsens Homescan Consumer Panel and make a difference. Limited availability!
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No Purchase Necessary To Enter.
A Purchase Won't Improve An Individual's Chance Of Winning


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