Do you have medicare?*

Yes

No

What Insurance do you have?*

Tell us about your Arthritis

Are you interested in learning about a medicine-free Pain Relief Solution at little or no cost^† from our partner Jencyn Medical?*

Yes

No

By selecting yes, I give my permission for Jencyn Medical to contact me by telephone or email regarding a medicine-free Pain Relief Solution; regardless of my status on any state or Federal Do Not Call, Mail, or Contact list. Privacy Policy.
^†Must qualify; deductibles and copayments may apply.

Are you diagnosed with gout and taking medication to treat it?*

Yes

No

Have you ever been diagnosed with osteoarthritis of the knee?*

Yes

No

Which of the following treatments have you received or are you currently receiving for your knee pain? *

Hyalgan^®, Supartz^®, Orthovisc^®, or Euflexxa^®

Synvisc-One (one injection)

SYNVISC^® (hylan G-F 20, three injections)

Steroid injection

None of the above

Tell us about your Diabetes

What type of diabetes do you have?*

Type 1

Type 2

Which method(s) best describe how you manage your diabetes?*

Oral

Insulin

Other

Are you interested in receiving your diabetic testing supplies at little or no cost^† from our partner US Medical Supply?*

Yes

No

By selecting yes, I give my permission for US Medical Supply to contact me by telephone or email regarding Diabetic supplies, products and services; regardless of my status on any state or Federal Do Not Call, Mail, or Contact list. Privacy Policy.
^†Must qualify; deductibles and copayments may apply.

Tell us about your Difficulty Walking/Mobility

Do you need assistance walking or moving around?*

Yes

No

Tell us more About You

Do you, your child, or someone you know have a severe allergy condition, such as food, insects, latex or medication?*

Yes

No

Would you or a loved one like to learn more about Clinical Research Studies around conditions such as Arthritis, COPD, Gout and more? Compensation may be available if you qualify. *

Yes

No

Have you or a loved one been diagnosed with cancer?*

Yes

No

Are you or a loved one considering treating with Chemotherapy? Sign-up to get a 2-part email series and find out what side effects doctors are most concerned about.*

Yes

No

By selecting yes, I agree to receive this email series from Alliance Health Networks via email. Privacy Policy.

Do you experience heartburn two or more times each week?*

Yes

No

Are you interested in learning about a non-surgical solution for back pain relief at little or no cost^† from our partner Infusion Resource?*

Yes

No

By selecting yes, I give my permission for Infusion Resource to contact me by telephone or email regarding back pain relief supplies, products and services; regardless of my status on any state or Federal Do Not Call, Mail, or Contact list. Privacy Policy.
^†Must qualify; deductibles and copayments may apply.

Has a doctor or specialist diagnosed you with Sleep Apnea, AND would you like to learn about saving on your CPAP supplies from our partner US Medical Supply?*

Yes

No

By selecting yes, I give my permission for US Medical Supply to contact me by telephone or email regarding CPAP supplies, products and services; regardless of my status on any state or Federal Do Not Call, Mail, or Contact list. Privacy Policy.
^†Must qualify; deductibles and copayments may apply.

By selecting yes, I agree to be contacted by Alliance Health Networks and home medical product companies contracted with Alliance; regardless of my status on any state or Federal Do Not Call, Mail, or Contact list. Privacy Policy.
^†Must qualify; deductibles and copayments may apply.

Do you personally experience excessive daytime sleepiness?*

Yes

No

Are you 49 years or older?*

Yes

No

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