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Levemir Care™ Registration

Registration

*Are you a Patient or a Caregiver?
*First Name
MI
*Last Name
*Patient's Date of Birth
/ /
*Parent or Guardian's Address 1
Parent or Guardian's Address 2
*City
*State
*Zip
Phone

Mobile Phone
May we have your permission to call you and review the benefits of Novo Nordisk
free patient support programs?

*Email
*Confirm Email
Password must be at least 6 characters long
*Password
*Confirm Password
*Security Question
*Answer
*Patient's Gender
*What type of diabetes do you have?

*What year were you diagnosed with diabetes?

*How often are injections taken? (All current diabetes medicines)


I agree that the information I am providing may be used by Novo Nordisk, its affiliates or vendors to keep me informed about new products, services, special offers, or other opportunities that may be of interest to me, as they become available. THESE COMMUNICATIONS MAY CONTAIN MATERIAL MARKETING OR ADVERTISING NOVO NORDISK PRODUCTS, GOODS, OR SERVICES. Novo Nordisk will take appropriate measures to protect my information. I can stop Novo Nordisk from sending me future communications by calling 1-877-744-2579, sending a brief note with my name and address to Novo Nordisk at 100 College Road West, Princeton, New Jersey 08540, or by clicking on the "unsubscribe" link, which will be available in future e-mail communications.

By providing my information to Novo Nordisk and acknowledging below, I certify that I am at least eighteen (18) years of age. I also understand that certain information pertaining to my use of the card will be shared by my pharmacy with Novo Nordisk, the sponsor of the card. The information disclosed will include the date that I filled the prescription, the number of pens dispensed by my pharmacist, and the amount that I will be reimbursed by Novo Nordisk under the Novo Nordisk savings card. This information will be available to Novo Nordisk and third parties working on behalf of Novo Nordisk and will not be shared with anyone else. To take advantage of this program, you must not reside in the state of Massachusetts and not be enrolled in any government, state, or federally funded medical or prescription benefit program. These would include Medicare, Medicaid, VA, DOD, and Tricare.