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Sample Basic Survey

The benefits of registering for patient support

Whether you are considering treatment or you are already taking KOMBIGLYZE XR, we’re here to help. Just fill out the form below and we’ll send you information that may help you throughout your journey with type 2 diabetes.

If you’re considering KOMBIGLYZE XR, you’ll receive information that can help you and your doctor decide if KOMBIGLYZE XR is right for you.

If you’re about to start or are already taking KOMBIGLYZE XR, you’ll receive: savings on KOMBIGLYZE XR, ongoing information and support, and prescription coverage support.

Subject to eligibility. Restrictions apply. Not available for government-insured patients. Savings subject to monthly limit.

Surround yourself with support. Sign up today.

By completing the registration, you may also receive ongoing information and support related to your condition, including treatment information.

AstraZeneca respects your personal health information. The information you provide may be used to send you health-related materials and to develop products, services, and programs. AstraZeneca, or third parties working on our behalf, will not sell or rent personal health information. If, in the future, you no longer want to receive health-related materials, call 1-800-236-9933. Please visit to review our Privacy Notice.


*Indicates required field.


By providing your date of birth, you verify that you are at least 18 years of age.

 Considering this medication?
 About to start taking this medication?
 Currently taking this medication?
 Yes, I would also like to receive information in the future about relevant AstraZeneca products, programs, and services that may be of interest to me.
 Yes, I would be willing to be contacted on occasion to participate in market research studies sponsored by AstraZeneca.
 Yes, I would be willing to share my experience as a patient taking KOMBIGLYZE XR with an AstraZeneca representative.