Diabetes assistance dog request form First name* : Last name* : If this request is for a child, names and first names of the parents* : Email* : Phone / Mobile : Your street and number* : Postal code* : City / Town* : Country* : Date of birth* : National number* : Contact person* : Phone / Mobile of contact person : AVIQ number, if you have one* : Are you diabetic? : Yes No Which diabetologist and where are you followed?* : Do you have a blood glucose monitoring device? : Yes No Are you satisfied with your device? : Yes No Can you send a copy of your glucose report for the last 15 days to pierre@os-mose.be? : Yes No Do you have any specific medical treatment? If yes, which one?* : Are you : Student Employee Self-employed Job seeker Other You live in a : Apartment without garden Apartment with garden House without garden House with garden Are you willing to come to Os'mose twice a week for about a year? : Yes No If you have a sensor, please send glucose curves from the last few weeks* : If you are not satisfied with your sensor, can you explain why? : How did you hear about Os'mose?* : What tasks will be required of the dog? : What are your daily and regular routines? What might your dog be exposed to?* : Privacy policy : Yes, I agree with the privacy policy Fields marked with * are required Send my message
