Patient Qualification Complete this form to see if you qualify for free Diabetic Shoes through Sole Care Outreach Qualification - COHEO Do you have diabetes? * Yes No Do you live in one of the following counties? Baker, Bradford, Calhoun, Columbia, DeSoto, Dixie, Franklin, Glades, Gulf, Hamilton, Hardee, Hendry, Holmes, Jackson, Jefferson, Lafayette, Levy, Liberty, Madison, Monroe, Nassau, Okeechobee, Putnam, Suwannee, Taylor, Union, Wakulla, or Washington * Yes No How did you learn about this program? * My health care provider Someone I know told me about it I saw a flyer posted I saw a social media post At an event OtherOther If you are human, leave this field blank. Submit Δ
