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PRESCRIPTION NOTE
Health Declaration
Please fill out the following health declaration form to order online medicine. Submissions are valid up to 24 hours prior to the activity.
First Name
Last Name
Email
Phone
My body temperature is lower than 98.6°F/ 37.5°C
Are you experiencing any flu symptoms?
No
Yes
Date
Initials
I confirm that the information given in this form is true
Email
Submit
Thanks for submitting!
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