Toujeo Coach Patient Referral Form

Please confirm that:

this patient is currently prescribed Toujeo®

this patient is over 18 years of age

this patient has

Patient Information

An asterisk (*) denotes a required field

Date of Birth

We will use the patient's email address only to contact them in connection with Toujeo Coach

Preferred contact day of the week (please check all relevant days)

Preferred contact time (please check all relevant contact times)

Healthcare Professional Confirmation

Receiving updates about this referral (Optional)
By checking the following box, I confirm that I have read and understood the Privacy Policy and I understand that my personal data (as provided below) will be stored and used by Ashfield in order for them to contact me about the progress of this patient through the Programme (provided the patient agrees), as described in the Privacy Policy.

I confirm that the patient has provided consent for me to refer them to the Toujeo Coach Programme.

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