Diabetic Discount Club



First Name:            Last Name:
Address:
Apt:                        City:
State:                      Zip:
Email:
Day Phone:

Your phone # will be part of your Unique Discount ID so be sure to enter it correctly.
Date of Birth:

Why do i need to provide this?
By checking this box, I give express consent authorizing Diabetic Discount Club, Your Diabetic Source, Diabetic Specialist and agents to verify my information by contacting me via automated telephone dialing system and/or recorded messages, text and emails whether I'm on any state or federal do not call list. Giving consent is not a condition for making any purchase.

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