MIDAS: Patient leaflet order form

Please fill in the below order form for patient information leaflets (maximum one of each booklet). Your order will be despatched as soon as possible.

Salutation *
First name *
Last name *
Address *
Town *
County *
Postcode *
Email address *
Telephone
Insulin *
Home monitoring diary (INS/346/0904F)
Type 1 diabetes (INS/567/0406)
Type 2 diabetes (INS/568/0406)
Help with hypos (INS/570/0406)
Permission for email marketing**
Comments

** The only occasion we will use your details, is to send you a questionnaire to find out what you think of our services, which will help us to improve the quality of the service we give our customers. See our personal data statement.

_{UK/DB/0308/0021}

_{Last updated: April 2008}