PT2 Pre-Enrollment Form - Blue Coral Coaching Solutions

Height*

Please select your current height in feet & inches from the list.

Weight*

Please enter your current weight in pounds (round to nearest whole number).

Now it's time to calculate your BMI.

Please enter the weight and height information you
just provided into the BMI calculator below.

Enter your BMI results from the calculator above*

I have previously been diagnosed with type 1 or type 2 diabetes*

Yes
No

I have been diagnosed with prediabetes.*

Yes
No

I am attaching a copy of medical lab results taken within the past 12 months.
They show an A1C level of (in percent) :

Attach a copy of medical lab results taken within the past 12 months.

A1C Level

(prediabetes range is 5.7 to 6.4)

and/or a blood glucose level of:

Blood Glucose Level

(prediabete range is 100 to 125 mg/dL)

Risk Test

Risk Test Score

If your score is 9 or more points, you are at high risk for prediabetes today

I believe I may have prediabetes as indicated by my Risk Test Score.

Agreements

I understand that submitting this form does not automatically enroll me in PreventT2. My information will be reviewed, and I will be informed of the next steps available to me.
PreventT2 requires medical screenings for eligibility and upon the program’s completion. I understand that I may be asked to submit to an A1C and/or blood glucose test, or to provide the results from testing by a third party.
I understand that PreventT2 involves one full year of my participation.
PreventT2 does not guarantee results. While the program will set a goal for me, I understand that my success depends primarily on how I apply PreventT2 skills and knowledge outside of our meetings.

Click checkbox to indicate your agreement*

I have read and understand the above agreements.

Signature*

Date*

I confirm that all the information entered here is correct and truthful.

Thank you for your interest in PreventT2!

We will contact you soon regarding next steps for your enrollment.

Call for next session start date.

If you have questions in the meantime, CONTACT: Gary Barclay by clicking here or call 928-421-1891

Phone
This field is for validation purposes and should be left unchanged.

PreventT2 Pre-Enrollment

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