Getting started with Omnipod® System is easy.
Just follow these 2 simple steps ...
1. Talk to your healthcare provider.

Set up an appointment with your healthcare provider to learn more about insulin pump therapy and whether or not it is right for you.

2. Call us or send us your information.
After deciding pump therapy is right for you, give us a call at 1.844.207.9982. To get you started, our team will work with you to make the process as easy as possible.
-OR-
If you’re ready to get started, simply complete the form below. Once we receive your paperwork our team will reach out to you as soon as possible.

Patient Information Form

Part A

Insulet Canada Corporation
1540 Cornwall Road, Suite 201 Oakville, ON L6J 7W5
Toll free 1.844.207.9982

Confidential Personal Health Information

Patient Information


Patient Name (First, Last): *
RadDatePicker
RadDatePicker
Open the calendar popup.

Date of Birth (YYYY/MM/DD)*

Parent / Guardian (For children under 18)

Best Phone Number to Reach You*

Street *
Preferred Method of Contact:

City *
select

Province *

Postal Code *
Are you currently using a pump? *

Email Address (parent/guardian, where applicable): *
How long have you been using your current pump?



Where did you hear about the Omnipod® System?

Current Pump Manufacturer

Clinic and Physician Information


Clinic Name *

City
select

Province

Postal Code

Clinic Phone Number

Clinic Fax Number

Diabetes Care Physician (First, Last) *

Diabetes Care Physician Phone Number

Diabetes Care Physician Email Address

Insurance

Have you registered or do you plan to register for provincial insulin pump program coverage?
Primary Health Insurance Coverage
Secondary Health Insurance Coverage

Policy Holder Name (First, Last)

Policy Holder Name (First, Last)
RadDatePicker
RadDatePicker
Open the calendar popup.

Date of Birth (YYYY/MM/DD)
RadDatePicker
RadDatePicker
Open the calendar popup.

Date of Birth (YYYY/MM/DD)

Relationship to Patient

Relationship to Patient

Employer

Employer

Insurance Company

Insurance Company

Insurance Policy #

Insurance Policy #

Insurance Certificate #

Insurance Certificate #