Forms

Forms

Diabetes Prevention Program

Use this form to sign up for HealthEast Diabetes Prevention Program...Getting Started.

The four-hour program is split into two sessions. Sessions meet from 9 to 11 am. Total cost for the class is $35.

Please note:
August and September sessions will be held at HealthEast Clinic - Maplewood (3100 Kennard Street, Maplewood, MN 55109). Beginning in October, sessions will be held at the new HealthEast Clinic and Specialty Center (2945 Hazelwood Street, Maplewood, MN 55109).

If you have any questions, contact Diabetes Care at 651-232-5757.

First name*
Please enter your first name.

Last name*
Please enter your last name.

Email address*
Please enter your email address.

Phone number*
Please enter your phone number

xxx-xxx-xxxx

Street address*
Please enter your street address.

City*
Please enter your city.

State*
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Zip code*
Please enter your zip code.

Date of birth*
/ / Please select your date of birth.

Select session dates*
Please select the class date you will be attending.

*
Please check the box to indicate you will bring payment to the first class session.


I will bring a check to the first class session or I will contact Diabetes Care at 651-232-5757 if I need financial assistance.