Check if you Qualify!

Name *

First Name

Last Name

Phone *

Country

(###)

###

####

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Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact *

First Name

Last Name

Emergency Contact Phone Number *

Country

(###)

###

####

Date of Birth

MM

DD

YYYY

Please indicate if you are currently taking any of the following medications: *

Aspirin

Anticoagulants (Blood Thinners)

Propanol, Verapamil (Arrythmia)

Diuretics (Water Pills)

Antihypertensive Drugs (Blood Pressure)

Digitalis (Heart)

Prednisone, Cortisone (Steroids)

None of the above

Please check if you currently have problems with any of the following: *

Liver (e.g. Cirrhosis, Hepatitis, Jaundice)

Kidneys

Spleen

Blood (Anemia, Leukemia)

None of the Above

Have you or anyone in your family ever had a serious bleeding problem? *

Yes

No

Don't know

Have you ever had prolonged or unusual bleeding from tooth extractions, cuts, surgeries or nosebleeds? *

Yes

No

Don't know

Do your gums bleed when you brush your teeth? *

Yes

No

Don't know

Are you pregnant *

Yes

No

Don't know

Do you have diabetes? *

Yes

No

Do you wake up to urinate more than once at night? *

Yes

No

Do you have muscle cramps or pains? *

Yes

No

Do you have a cough or cough frequently? *

Yes

No

Don't know

Do you have epilepsy or suffer from fits or seizures? *

Yes

No

Don't know

Do you have neck or back problems? *

Yes

No