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How did you hear about us?
Marta (Fulton, Dekalb and Clayton County Area)
Family, Friend, Co-worker
Internet ( Internet Facebook, Instagram)
If referred by family, friend or co-worker, please provide their name here.
Your full name
Contact Number (ex.4045056262)
What county you live in?
Employment Status/Source of Income
Self Employed (ex.1099, Gig worker, Uber/Lyft, Realtor, Paid Cash)
Social Security Disability
Do you currently have Health Insurance?
If you answered "yes", please complete below as to the type of Insurance you may have.
Major Medical from Employer
Healthcare.gov (Marketplace Health Insurance Plan)
Not sure what type
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