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Name
Phone Number
E-mail Address
Were you a patient at one of the clinics in question?
Yes No
Did you receive anesthesia or sedation injections?
Have you been tested recently for hepatitis or HIV?
Yes, Tested Positive Yes, Tested Negative Yes, Results Pending No, Not Tested
What side effects did you suffer?
Were you married or engaged while being treated at one of the clinics in question? Yes No
Do you have any children? Yes No
Were you or your significant other pregnant during the time you were treated by the clinic in question? Yes No
Additional Details