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Application to get on Waitlist

Please fill out the following form to help us understand your physical condition.

First Name

Email Address

Last Name

Date of Birth

Have you been hospitalized in the last 12 months?

No

Yes

Are you currently suffering from a medical condition, illness, or injury?

No

Yes

If you answered yes to any question, please elaborate

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I declare that the info I’ve provided is accurate & complete

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© 2020 by Dr. Rosa Lee MD CCFP

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