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Health Intake Form

Please fill out the following form.

Date of birth
Do you have any of the following?
High Blood Pressure
Diabetes
Have you been hospitalized in the last 12 months?
No
Yes
Are you suffering from a medical condition, illness or injury?
No
Yes
How often do you have bowel movements?
Daily
2-3 times a week or more
Never

HOURS:

9:00 AM-4:00 PM Pacific Standard Time 

12:00 PM-7:00 PM Eastern Standard Time

Monday-Friday

Closed Saturdays & Sundays

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For basic inquiries and product recommendation:

442-400.8023 

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