s Corporation. a Johnson & Johnson Company.

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I want to know more.

I want to know more.

Fill in the form below and we'll contact you as soon as we can. We will be happy to send you information on our products or discuss next steps in getting your Animas™ insulin pump. We look forward to being of service!

Note: If this is a pump emergency, please call the number on the back of your pump as messages from this form are not monitored 24/7.

* Required

Age*

<13 13-18 19-30 31-40 41-60 >60

First Name*

Last Name*

Message Category*

I want to be contacted about the Animas™ 2020 insulin pump. I want to be contacted about the inset™ 30 infusion set. I want to be contacted about the inset™ II infusion set. I want to be contacted about the ezManager™ Plus software. I want to send a comment or ask a question. I want to request Animas literature.

My Diabetes

I am interested in products for:

My diabetes My child's diabetes Other reason (please detail)

I have been diagnosed with:

Type 1 Diabetes Type 2 Diabetes

My last HbA1c was:

Greater than 8.5 Lower than 8.5 Don’t know

I experience disabling hypos (requiring 3rd Party Assistance):

Frequently Occasionally Never

I have discussed Insulin Pump Therapy previously with my Diabetes Specialist Nurse or Consultant:

Yes No

Comments/How did you hear about us? (optional)

Privacy: We will fulfill your request to be contacted if you check the boxes expressing your contact preference and provide the required information. We may also send you information in which we think you might be interested if you select that option. Your name and other information provided will be available to Animas United Kingdom & Ireland. The information you submit will be governed by our Privacy Policy, and may be transferred to other countries, including the United States, that may not have equivalent laws to protect such information. You can request that your information be removed at any time from our contact list by emailing us at AnimasUK@its.jnj.com. By checking of “I have read and agreed to the terms of the Privacy Policy and the Legal Notice”, you agree that the information you submit will be governed by our Privacy Policy.

I have read and agree to the terms of the Privacy Policy and the Legal Notice.*

I want to receive diabetes-related information and promotional offers from Animas Corporation.

 

Form last updated on: January 13, 2009