Self-Inject Client Profile and Consent
Today's Date *
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Name (First and Last) *
Your answer
Date of Birth *
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YYYY
Age *
Your answer
Allergies (drug) *
Your answer
Email address (for self-inject instructions) *
Your answer
Address (include City State and Zip) *
Your answer
Phone number (with area code) *
Your answer
Have you ever self-injected? *
What type of kit did you purchase? (e.g. Lipotropic B12; Glutathione) *
Your answer
How did you hear about us? *
Your answer
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