APPOINTMENTS

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Address: *

Address Line 1

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Email: *

Gender: *

Date of Birth: *

Are you Diabetic? *

Please identify what type of Diabetic you are: *

Are you taking any Anticoagulants (blood thinners)? *

What Pharmacy do you deal with? (optional)

Who is your Primary Care Provider? (optional) *

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Terms of Service *

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