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What is your date of birth?

DO YOU HAVE THE FOLLOWING SYMPTOMS? PLEASE CHECK ALL THAT APPLY

DO YOU HAVE THE FOLLOWING? PLEASE CHECK ALL THAT APPLY

DO YOU HAVE ANY OTHER HEALTH CONDITIONS OR CONCERNS?

IS THERE ANYMORE IMPORTANT INFORMATION WE SHOULD KNOW?

ARE YOU CURRENTLY TAKING ANY MEDICATIONS? PLEASE INCLUDE OVER THE COUNTER MEDICATIONS AND HERBAL OR VITAMIN SUPPLEMENTS

ARE YOU ALLERGIC TO ANY MEDICATIONS?

TREATMENT OPTIONS

PLEASE ENTER YOUR PREFERRED PHARMACY INFORMATION HERE

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Total Payment Value: $25.00