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*Are you a Patient or a Caregiver?
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*Date of Birth
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*Novo Nordisk Instant Savings Card
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Your Diabetes

*What type of diabetes do you have?

*What year were you diagnosed with diabetes?

*When is your next scheduled visit with a health care provider to talk about your diabetes?

I agree that the information I am providing may be used by Novo Nordisk, its affiliates or vendors to keep me informed about new products, services, special offers, or other opportunities that may be of interest to me, as they become available. Novo Nordisk may also combine the information I provide with information from third parties so as to better match these offers with my interests. THESE COMMUNICATIONS MAY CONTAIN MATERIAL MARKETING OR ADVERTISING NOVO NORDISK PRODUCTS, GOODS, OR SERVICES. Novo Nordisk will take appropriate measures to protect my information. I can stop Novo Nordisk from sending me future communications by calling 1-877-744-2579, sending a brief note with my name and address to Novo Nordisk at 800 Scudders Mill Road, Plainsboro, New Jersey 08536, or by clicking on the "unsubscribe" link, which will be available in future e-mail communications. By providing my information to Novo Nordisk and acknowledging below, I certify that I am at least eighteen (18) years of age.

I also understand that Novo Nordisk offers savings cards on many of its products and eligiblity restrictions apply to these offers. I understand that I may not take advantage of these programs if I am enrolled in any government, state, or federally funded medical or prescription benefit program. These include Medicare, Medicaid, VA, DOD, and TRICARE. If eligible, I understand that certain information pertaining to my use of the card will be shared by my pharmacy with Novo Nordisk, the sponsor of the card. The information disclosed will include the date that I filled the prescription, the number of pens dispensed by my pharmacist, and the amount that I will be reimbursed by Novo Nordisk under the Novo Nordisk savings card. This information will be available to Novo Nordisk and third parties working on behalf of Novo Nordisk and will not be shared with anyone else.

Selected Important Safety Information

What should I tell my health care provider before taking Levemir®, NovoLog®, or NovoLog® Mix 70/30?

  • About all of your medical conditions.
  • If you are pregnant, plan to become pregnant, or are breastfeeding.
  • About all prescription and over-the-counter medicines you take, including supplements.

Talk to your health care provider about how to manage low blood sugar.

How should I take Levemir®, NovoLog®, or NovoLog® Mix 70/30?

  • Read the Instructions for Use and take exactly as directed.
  • Take Levemir®, NovoLog®, or NovoLog® Mix 70/30 as directed by your health care provider. Do not change your dose or type of insulin unless you are told to by your health care provider.
  • Check your blood sugar levels as directed by your health care provider.
  • Do not share needles, insulin pens, or syringes. You may give or get an infection from another person.

What are some possible side effects of Levemir®, NovoLog®, and NovoLog® Mix 70/30?

Serious side effects can lead to death, including:

  • Low blood sugar, including when too much is taken. Some symptoms include anxiety, irritability, mood changes, dizziness, sweating, confusion, and headache.

Get emergency medical help if you have:

  • trouble breathing, shortness of breath, fast heartbeat, swelling of your face, tongue, or throat, sweating, extreme drowsiness, dizziness, or confusion.

Please click here for additional Important Safety Information