PACED Pump Program

Expression Of Interest

  • Personal Details
  • Expression Of Interest
  • Healthcare Professional Details
  • Declaration & Submit

Personal Details

Title

First Name

Middle Name

Last Name

Date diagnosed with Type One Diabetes.

Current Therapy

If other to the above question please provide details.

Gender

Date Of Birth

Contact Number

Email Address

Address

Suburb

State

PostCode

If applicant is under 18 years of age at date of application. Please provide parent/guardian details.

Name of parent/guardian

Contact Number

Email Address

Relationship to applicant

If other please provide details.

Expression Of Interest

I am applying for? (please note CGM will only be offered to those over the age of 21.The Australian Government is now providing access to fully subsidised continuous glucose monitoring (CGM) products through the National Diabetes Services Scheme (NDSS). Subsidised access to CGM sensors and transmitters is available through the NDSS to children and young people aged under 21 years, living with type 1 diabetes, who meet specific criteria. )

Let us know why you should receive a MiniMed 640G and / or Continuous Glucose Monitoring?

Why do you want to change to insulin pump therapy?

How do you believe Continuous Glucose Monitoring will improve your type one diabetes management?

Have you / or your child been hospitalized as a result of Type One Diabetes in the last 12 - 24 months?

If Yes to the above question please provide details below.

Please share any details which you feel may support your application.

Please upload any documents which may support your application.

Healthcare Professional Details

Title

Name

Occupation

Hospital / Clinic

Email

Contact No.

Address

Suburb

State

Postcode

Declaration & Submit

By clicking on the circles below i agree to the PACED Pump Program eligibility criteria and privacy policy.