FormPlatinum

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    Forms_Step_1

    Step-1: Fill the Application form

    Please provide the information about you

    Step-2: Medical symptoms

    What is/are the main medical problem(s) which you currently have or have had in the past?

    Are you RENEWING your recommendation (Have you had a recommendation in the last 10 years)?

    Do you currently use specific medications for your medical condition?

    Are you taking any prescription medications or herbs?

    Do you have any allergies to any medications?

    Have you ever had any surgeries or been hospitalized?

    Do you exercise?

    Do you smoke tobacco?

    Do you drink alcohol?

    Are there health/medical problems that occur frequently in your family?

    Have you experienced or been diagnosed with any of the following