Diabetes Prevention Program Online Application

Secure enrollment form Please complete this form on a private device. Medical and enrollment information may be HIPAA-sensitive.

Eligibility Screening

Help us confirm basic DPP eligibility and available health metrics.

Age *

Must be 18+

Weight (lbs) *

Height (ft/in) *

BMI

Auto-calculated or entered manually

Have you been diagnosed with prediabetes? *

Yes No Not sure

Have you been diagnosed with Type 2 Diabetes? *

Yes No

Are you currently pregnant? *

Yes No N/A

Blood Test Result (if available)

A1C or fasting glucose value

Personal Information

Tell us who is applying and how to reach them.

First Name *

Last Name *

Date of Birth *

Gender *

Male Female Non-binary Prefer not to say

Race / Ethnicity

Phone Number *

Email Address *

ZIP Code *

Insurance & Referral

Insurance and referral details help us coordinate program enrollment.

Insurance Provider

Member ID

Referred by Physician?

Yes No

Referring Physician Name *

Referring Physician Phone *

Program Consent

Confirm program participation and required data-sharing consent.

I agree to participate in the DPP program *

I consent to sharing de-identified data with the CDC *

Signature *

Full legal name (e-signature)

Date *

Contact Info

Patient Portal

Diabetes Prevention Program Online Application

Eligibility Screening

Personal Information

Insurance & Referral

Program Consent