P.O. Box 11521

Montgomery, AL 36111

800.800.1198

FREE health coaching

“helping transportation professionals arrive home safer, healthier & happier“

Wellspark Enrollment

WellSpark Diabetes Prevention Program Enrollment

Step 1 of 6

What is your Name?*
First Last
What is your email address?*
What is your mobile number?*
In which state do you live?*
How did you hear about the program?*
Lead Source
Subject
Are you a Veteran?
Lead Category
Date
Date Format: MM slash DD slash YYYY

Consent?*
By clicking NEXT, you have agreed to the following: You have read and understand the information in this document, You are willing to share your contact information with WellSpark, and HTAA, You agree to be contacted by an HTAA Health Coach, and If you are eligible and you enroll in the WellSpark diabetes prevention program, you agree to allow WellSpark to share identifiable information (see What information will be collected and shared? section above) with HTA.
Please enter why you have chosen not to consent.

Are you an owner operator or do you work for a fleet?*
What is your Trucking Company’s Name?*

Which category best describes your age?*
What was your assigned sex at birth?*

In the past 12 months, have you been told by a health professional that you have prediabetes or an A1c of 5.7% to 6.4%?*

Which one of these categories describes the number of miles or hours you drive each day on average?*
How would you describe the size of the trucking fleet you work for?

questions? Call 800-800-1198 to talk to a health coach

“Helping Transportation Professionals Arrive Home Safer, Healthier & Happier”

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