Email Address :
First Name :
Last Name :
Title :	Select title MD RN Clinic Director IT NP PA Other
Hospital / Clinic Name :
Address (or P.O. Box) :
Address (Slot#/Room# ) :
City :
State :	Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware D.C. Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip :
Daytime Phone # :	Ext:
Other Phone # :	Ext:
How did you hear about DMClinic?	Select How you heard about DMClinic I am a current Standing Stone customer Postcard/mailer Internet search Meter rep Other
Number of patients you are managing or planning on managing :	Select Number < 100 100 - 500 > 500 > 1000
Software you are currently using to track your diabetes patients (if any):
Point of Care meter you are using or plan on using (if any):	Select Point of Care meter Bayer DCA 2000 (HgA1C) Metrika A1CNow (HgA1C) Accuchek Inform (Glucose) Other None
Other Meter:
Which best describes your clinic?	Starting a clinic Have an existing clinic

49 Richmondville Avenue, Westport, CT 06880   Tel: (800) 648-9877   E-mail: info@standingstoneinc.com