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First Name *

Last Name *

Address (include Appartment or suite. No PO BOX delivery***) *

City *

Postal Code (Format A1A 1A1) *

Email *

Phone (may be needed for purposes of delivery or mandated communications) *

PLEASE NOTE: Limit of one offer per person. This offer is conditional upon availability on inventory and is subject to change, substitution or termination at any time to the sole discretion of Roche Diabetes Care.

* Mandatory fields.
** Purchase of Accu-Chek Guide strips might be required. This offer only applies to a new Accu-Chek Guide user. Limit of one (1) offer per person for a period of 12 months; additional requests will not be processed.
*** No request will be delivered to a post office box. A full physical address is mandatory.

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