BE THE FACE OF CHANGE NEW FACE APPLICATION
Note to Applicants
You must submit a current photograph of yourself with this application form (completed and signed) to be considered.
You must be 18 years of age or older to participate.
If you would prefer to mail in your application, please download the printable PDF version of this form.
If you do not have Adobe® Reader® you can get it here.
Levemir® (insulin detemir [rDNA origin] injection)
Levemir® (insulin detemir [rDNA] injection) is a man-made long-acting insulin that is used to control high blood sugar in adults and children with diabetes mellitus.
Check your blood sugar levels. Ask your health care provider what your blood sugars should be and when you should check your blood sugar levels. Alcohol, including beer and wine, may affect your blood sugar when you take Levemir®.
Do not change the type of insulin you use unless told to do so by your health care provider. The amount of insulin you take as well as the best time for you to take your insulin may need to change if you take a different type of insulin.
Never mix Levemir® with other insulin products or use in an insulin pump.
Do not take Levemir® if your blood sugar is too low (hypoglycemia) or if you are allergic to anything in Levemir®. If you take too much Levemir® your blood sugar may fall too low.
Tell your health care provider about all medicines you take and all of your medical conditions, including if you are pregnant or breastfeeding. Your Levemir® dose may change if you take other medicines.
The most common side effect of insulin therapy, including Levemir® is low blood sugar (hypoglycemia). Other possible side effects include reactions at the injection site (like redness, swelling and itching), and allergic reactions. Get medical help right away if you experience signs of serious allergic reaction such as body rash, trouble with your breathing, fast heartbeat, or sweating. Ask your doctor or pharmacist for further information.
NovoLog® (insulin aspart [rDNA origin] injection)
NovoLog® is a man-made insulin that is used to control high blood sugar in adults and children with diabetes mellitus.
NovoLog® is a fast-acting insulin. You should eat a meal within 5 to 10 minutes after using NovoLog® to avoid low blood sugar. Do not inject NovoLog® if you do not plan to eat right after using NovoLog®. Check your blood sugar levels. Ask your health care provider what your blood sugars should be and when you should check your blood sugar levels. Alcohol, including beer and wine, may affect your blood sugar when you take NovoLog®.
Do not change the type of insulin you use unless told to do so by your health care provider. The amount of insulin you take as well as the best time for you to take your insulin may need to change if you take a different type of insulin.
Do not mix NovoLog® with any other insulins when used in a pump or with any insulins other than NPH when used with injections by syringe.
Do not take NovoLog® if your blood sugar is too low (hypoglycemia) or if you are allergic to anything in NovoLog®. If you take too much NovoLog® your blood sugar may fall too low.
Tell your health care provider about all medicines you take and all of your medical conditions, including if you are pregnant or breastfeeding. Your NovoLog® dose may change if you take other medicines.
The most common side effect of insulin therapy, including NovoLog® is low blood sugar (hypoglycemia). Other possible side effects include reactions at the injection site (like redness, swelling, and itching) and allergic reactions. Get medical help right away if you experience signs of serious allergic reaction such as body rash, trouble with your breathing, fast heartbeat, or sweating. Ask your doctor or pharmacist for further information.
NovoLog® Mix 70/30 (70% insulin aspart protamine suspension and 30% insulin aspart injection, [rDNA origin])
NovoLog® Mix 70/30 (70% insulin aspart protamine suspension and 30% insulin aspart injection, [rDNA origin]) is a man-made insulin that is used to control high blood sugar in adults with diabetes mellitus.
NovoLog® Mix 70/30 is a pre-mixed insulin. You should eat a meal within 15 minutes after using NovoLog® Mix 70/30 to avoid low blood sugar. Do not inject NovoLog® Mix 70/30 if you are not planning to eat within 15 minutes. Check your blood glucose regularly. Ask your health care provider what your blood sugars should be and when you should check your blood sugar levels. Alcohol, including beer and wine, may affect your blood sugar when you take NovoLog® Mix 70/30.
Do not change the type of insulin you use unless told to do so by your health care provider. The amount of insulin you take as well as the best time for you to take your insulin may need to change if you take a different type of insulin.
Never mix NovoLog® Mix 70/30 with other insulin products or use it in an insulin pump.
Do not use NovoLog® Mix 70/30 if your blood glucose is too low (hypoglycemia) or if you are allergic to anything in NovoLog® Mix 70/30. If you take too much NovoLog® Mix 70/30 your blood sugar may fall too low.
Tell your health care provider about all medicines you take and all of your medical conditions, including if you are pregnant or breastfeeding. Your NovoLog® Mix 70/30 dose may change if you take other medicines.
The most common side effect of insulin therapy, including NovoLog® Mix 70/30 is low blood sugar (hypoglycemia). Other possible side effects include reactions at the injection site (like redness, swelling and itching), and allergic reactions. Get medical help right away if you experience signs of serious allergic reaction such as body rash, trouble with your breathing, fast heartbeat, or sweating. Ask your doctor or pharmacist for further information.
FlexPen®, Levemir®, and NovoLog® are registered trademarks of Novo Nordisk A/S.
© 2009 Novo Nordisk Inc. 135082-R1
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