Order your BREEZE^®2 Meter

Getting your FREE BREEZE^®2 Meter is simple. Take just a minute to fill out the questionnaire below.

(In order to receive your FREE meter upgrade, please complete all required fields. Available only to US customers)

The limit is one free meter per customer and is available only to those living in the US. The meter must be for personal use only. The upgrade meter can not be sold nor shall you seek any payment from a third party payor. Product will be shipped within 3 to 7 days, however, please allow up to 6 to 8 weeks for delivery.

*First Name	*Last Name
E-mail Address
Daytime Phone	Evening Phone
*Address	Alt Address
*City
*State	*Zip Code
---Please Select--- AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
*Date of Birth of Meter User
Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900
How often do you test your blood glucose?	Select More than twice a day Twice a day Once a day Not every day
How do you control your diabetes?	Select Insulin injections/needles Oral medications/pills Diet and exercise Insulin pump Both insulin and oral medication Other
What type of health care coverage do you have for your blood glucose meter and strips?	Select No Coverage Medicare Medicaid Managed care plan or private insurance Medicare plus other coverage Other
Where will you purchase your test strips?	Select Retail pharmacy Mail order Other
What blood glucose monitoring system, if any, were you previously using?	NONE, first time user Abbott Precision Xtra/Qid AccuChek® Active AccuCheck® Advantage AccuChek® Aviva AccuChek® Compact/Plus ELITE® or ELITE® XL DEX® 2 BD Logic/Latitude BREEZE®/BREEZE®2 CONTOUR® Freestyle®/Flash®/Lite® OneTouch® Ultra®/Ultra Smart®/Ultra2® Other

Privacy Statement:
Bayer respects your right to privacy. Your personal and medical information will be kept confidential. It will not be shared with any third parties or outside mailing lists.


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