Registration Form - Diabetes Program

Register for our free service

Please take a moment to complete the form below and an IDS representative will contact your clinic to arrange installation date.

The information on this form will be used strictly for registration purposes and will NOT be shared with any third-party organizations.

Contact Information * indicates a required field
Clinic Name:
First Name: *
Last Name: *
Email address:
Mailing address: *

City: *
Province: *
Postal code: *
Daytime telephone: * must be 10 numbers in length	- -
Fax number:	- -
Clinic Information
How many educators in your clinic? *
Waiting room capacity:
Approx. number of patients per day in entire clinic: *
Note: The display unit remains the property of IDS Canada Inc. We guarantee there is no charge for the service, now or in the future. The information on this form will be used strictly for registration purposes for this service and will not be shared with any third party organization. Upon completing the form, IDS will contact your clinic to arrange an installation date. For further information regarding the diabetes program, please contact us at 1-877-656-9996.
Agreement By submitting this form, I, the contact person listed above, understand that IDS Canada will be contacting me to discuss setting up an appointment for an installation date. I also understand the program is free and there are no charges for this service, and the display unit will remain the property of IDS Canada.