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Please read our Privacy Policy and HIPAA Privacy Notice for details on how we manage and protect your information below. We value your privacy and appreciate the trust you place in us by providing it.

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* First Name

* Last Name

* Zip Code

* Email Address

* Preferred Phone

* Type of Diabetes Please Select Type 1 Type 2: Using Insulin Other/Unsure

* I certify I am 18 years of age or older. If you are under 18, please ask your parent or guardian to order on your behalf.

* I acknowledge I have been provided access to the Insulet Corporation Privacy Policy and HIPAA Privacy Notice concerning the use and disclosure of my medical information.

* I authorize Insulet Corporation, its distributors, affiliates and wholly-owned subsidiaries to contact me by telephone or e-mail regarding the Omnipod Insulin Management System and other diabetes-related supplies and services.

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Note: You must be a resident of the United States to request a Demo Kit