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Your Full Name : *
Email Id : *
Mobile Nu : *
Occupation : *
Sex : *
Age : *
Weight : *
Body type *
Marital Status *
Lifestyle
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Any Problem you are facing ? *
Do you happy with your sexual life Rate 5 out of ? *
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Do you have Diabetes ? *
( If yes ) How much Diabetes ?
Do you have Blood Pressure ? *
( If yes ) How much Blood Pressure ?
Do you have any types of disease like gonorrhea ? *
Do you have habituated with any types of drugs ? *
(If yes) What are those ?
Which type of medicine taking before ? *
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Medicine Delivery Address (with country and postcode ) :- (If you want medicine at your Door Step) *
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