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CONFIDENTIAL PATIENT INFORMATION FORM

PLEASE COMPLETE THE INFORMATION AND SUBMIT THE FORM. THANK YOU.

Sex
MM slash DD slash YYYY
Maritial Status
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This will let us send you important information.

*There will be a restocking fee for any returned suppliments.

PLEASE ANSWER THE FOLLOWING 3 QUESTIONS:

1) Do you ever buy bottled water?
2) Have you ever joined a health club?
3) Do you use vitamins and or other nutritional supplements?