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Type 2 Diabetes
How Revita Works
The Process
Do I Qualify?

Do I Qualify?

The first step in determining if you qualify is filling out the questionnaire:

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See if you qualify
Do you have type 2 diabetes?*
- Yes
- No
Are you 18 years or older?*
- Yes
- No

See if you qualify
Do you take oral and/or injectable glucose lowering medications and/or long-acting insulin therapy?*
- Yes
- No
- Unsure
When was the last time your HbA1c was checked?*
- Within past 3 months
- More than 3 months

See if you qualify
Candidate information:
First Name*
Last Name*
Email Address*
Phone Number
Cell Phone Number
Post Code*

See if you qualify
Please enter your height and weight below to calculate BMI (Body Mass Index)
Height*
Weight*

See if you qualify
Was your HbA1c between ≥7.0 and ≤10.0% (53-86 mmol/mol) in the past 3 months?*
- Yes
- No
- Unsure
User Agreement
I understand that the personal information I have provided may be collected, shared, used and/or transferred by the Care Coordinator for the sole purpose of enabling me to be contacted.
User Agreement*
- I agree
- I disagree

See if you qualify
Clinical Registry A clinical registry is a secure database designed to collect information about new therapies and clinical experiences among patients in a real-world setting. All data will be treated confidentially and will help doctors make decisions to provide the best possible care for patients.
Are you interested to voluntarily participate in a clinical registry?*
- Yes
- No
- Unsure

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