Terms, Conditions & Final Submission
I acknowledge and understand that under this Dexcom trial program I am eligible to receive a Dexcom CGM (sensor and transmitter only). The purpose of this sample is to allow me, together with my prescribing healthcare provider, to evaluate the functionality of the Dexcom Continuous Glucose Monitoring (CGM) System for management of my diabetes and to evaluate whether the Dexcom CGM System may be right for me. I authorized Dexcom to use the protected health information I provided solely for the purpose of determining eligibility for a CGM sample.
I understand that I have no obligation to purchase any products or services from Dexcom, either as part of this sample program or after the sample period.
I understand that this Dexcom CGM sample does not come with a Dexcom receiver and that by my acceptance of the sample I represent to Dexcom that I have reliable access to a compatible mobile smart device and, if applicable, Tandem Control-IQ / Basal-IQ insulin pump or Omnipod 5, and I am capable of safely using a Dexcom CGM sample with my compatible mobile smart device, without the need for a separate dedicated receiver during the 10-day or 15-day sample period.
I understand that my compatible mobile smart device must be charged and have a broadband signal to display my glucose readings and push alrets and that if it is not set up or used correctly, I may not receive glucose readings, alarms or push alerts.
I agree to use the Dexcom CGM sample in accordance with the included Indications for Use. I understand that if I have any concerns about my access to or ability to use a Dexcom CGM sample with a mobile smart device, I should not accept the Dexcom CGM sample for use, and should speak to my healthcare provider. I understand that this Dexcom CGM sample is being provided to me without charge and I agree that I will not sell, barter, return for credit or seek reimbursement for this sample from any source, nor will I give or transfer it to any other person to use.
I further represent to Dexcom that I meet the below eligibility requirements for the Dexcom CGM sample and that I authorize Dexcom to request a prescription for the Dexcom CGM from my treating healthcare provider, using the contact information that I provide.
I understand that Dexcom may modify or rescind this offer at any time without notice.
I agree to Dexcom’s Terms of Use and Privacy Policy, and agree that Dexcom (or a service provider on behalf of Dexcom) may (1) use my information to communicate with me about Dexcom products, services and programs, or to provide me with information relating to my healthcare treatment, payment for healthcare, or other health information or care coordination services, in accordance with such terms; and (2) contact me at the phone number and email address set forth above, and use automatic dialing machines, automated, pre-recorded voice messages, and may send SMS/text messages. I understand that I may opt out at any time by texting “STOP” in return to a text or by calling Dexcom at 888-738-3646, and that my consent to this contact is not required for the purchase of Dexcom products or services. I understand that my service provider’s airtime, message and data rates may apply. In addition, I certify that I (i) am the patient referenced above or (ii) am the parent or legal guardian of the patient referenced above, and that I am at least eighteen (18) years of age.*