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First Name

Email

Last Name

Code

Phone

City

Country

Region/State/Province

Gender

Male

Female

Height

Weight

Are you a Diabetic?

Yes - Type 1 Diabetes

Yes - Type 2 Diabetes

Pre-Diabetic

No

Fasting Blood Sugar (mg/dl)

Less than 100

100 to 119

120 to 149

Over 150

I'm not sure

Post Prandial Sugar Levels (2hrs post meal)

Less than 150

150 to 199

200 to 249

250 to 299

Over 300

I'm not sure

HbA1c - 90 Day Average Blood Sugar

Between 6 and 7

7.1 to 9

Above 9

I'm not sure

Pre-Existing Medical Conditions

High Blood Pressure (Hypertension)

High Cholesterol

Cardiac Issues

Obesity

Kidney Issues

Other

None of the Above

Reason for Consultation

How Should We Contact You?

Phone (within ~72 hrs)

Whatsapp (within ~48hrs)

Email (within ~48hrs)

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