MyVoice® Diabetes Care Questionnaire

Subscribe to receive Diabetes Care offers from MyVoice®.

Veuillez cliquer ICI pour remplir le questionnaire en français.

Mr Mrs Miss Ms
Name Name * First Last
Email *

Please provide your email address.
Address Line 1 *
Address Line 2
City *
Province/Territory *
Postal Code *
Must be 6 characters. Currently Entered: 0 characters.
Please provide your home postal code (without space or dash) so we can send you offers available within your area as some offers may not be available in your province.
Permission *

Permission I give my consent to receiving online and physical mail communications from MyVoice® related to promotions, offers, coupons and all other related content. I am aware that I may withdraw my consent at any time by sending an email to contactus@my-voice.ca or by mail at Privacy Officer, 4-465 Milner Ave., Toronto, ON M1B 2K4.

Respecting your privacy is important to us (click here to review our privacy policy).
Diabetes Management

(check all that apply for the household)
1) If a household member has diabetes, please indicate the diabetes type. *

1) If a household member has diabetes, please indicate the diabetes type. Type 1 Type 2 Gestational
2) How do household members manage diabetes? *

2) How do household members manage diabetes? Insulin injection Insulin pump Oral medication or pills Diet and exercise Other Other
3) Please indicate the diabetes meters used in your household.

3) Please indicate the diabetes meters used in your household. Accu-Chek Dexcom G6 CONTOUR NEXT or Breeze FreeStyle Libre 2 FreeStyle Libre FreeStyle or Precision OmniPod OneTouch Ultra 2 OneTouch MediSure LifeScan Other meters
4) How often is a meter used?

4) How often is a meter used? 3 or more times per day 1 or 2 times per day Less than once per day
5) Which insulin brands are used in the household?

5) Which insulin brands are used in the household? Apidra Basaglar Entuzity Fiasp Humalog Humulin Lantus Levemir NovoRapid / NovoLog Novolin Toujeo Tresiba Other insulin brands
Thank You

Thank you for taking the time to complete this questionnaire. If you are qualified to receive Diabetes Care offers, you will receive the materials in the mail (if postal address provided) and/or email.

Please submit your questionnaire by clicking the Submit button below once.

Sincerely, MyVoice Team

MyVoice® Diabetes Care Questionnaire

MyVoice® Diabetes Care Questionnaire

Diabetes Management

Thank You