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sex

What is your date of birth?

DO YOU HAVE ANY OF THE FOLLOWING? PLEASE CHECK ALL THAT APPLY

PLEASE CHECK ANY OF THE FOLLOWING THAT APPLY TO YOU

DO YOU HAVE OTHER MEDICAL HEALTH ISSUES?

PLEASE LIST

ARE YOU ALLERGIC TO ANY MEDICATIONS?

PLEASE LIST

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

PLEASE LIST

TREATMENT

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Total Payment Value: $25.00