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What is your date of birth?

HAVE YOU EVER HAD A COLD SORE BEFORE?

DO YOU WANT TO TREAT A CURRENT COLD SORE OR PREVENT FUTURE COLD SORES?

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

WHEN DID THE COLD SORE APPEAR?

PLEASE CHECK ANY OF THE FOLLOWING STATEMENTS THAT APPLY TO YOU

HAVE YOU EVER HAD COMPLICATIONS FROM A COLD SORE? PLEASE CHECK ALL THAT APPLY

DO YOU HAVE ANY CURRENT MEDICAL CONDITIONS?

DO YOU HAVE ANY ALLERGIES?

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

ANYTHING ELSE WE SHOULD KNOW?

TREATMENT

PLEASE ENTER YOUR PREFERRED PHARMACY INFORMATION HERE

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Total Payment Value: $25.00