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First Name

Last Name

Phone Number

Email Address

Date of birth

Select the primary condition for which you are seeking treatment?
—Please choose an option—Chronic PainArthritisAnxietyInsomniaOther

How long has this condition been present?
—Please choose an option—Less than 3 months3-6 months6-12 months1-3 yearsMore than 3 years

Have you had any prior experience with alternative prescription medicines?
—Please choose an option—YesNo

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