Please read in full and sign with your name, email, and signature below.Please complete this questionnaire as thoroughly as possible. It is very important to be aware of any medical conditions, medications, supplements, life experiences, or habits that can influence your experience. Our interest is in helping you have a safe and beneficial experience. This is a confidential record.

Note, you are able to save this form and return to it later by clicking either the “Next’ button or “Save Draft” at the bottom of each page.

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