Interest Form

Please fill out the form below and an employee from Crook County Health Department Diabetes Prevention Program will contact you to find out if you qualify.

Type of Referral*
Name*
Date of Birth*
Address*
Have you been diagnosed with type 1 or type 2 diabetes?*
Have you been diagnosed with prediabetes?*
Do you have a family history of type 2 diabetes?*
Have you been diagnosed with High Blood pressure?*
I am interested in:*
MM slash DD slash YYYY
I agree that the program coordinator can contact me to find out if I qualify*
This field is for validation purposes and should be left unchanged.