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Name*
First Last
Date of Birth*
Date Format: MM slash DD slash YYYY
Phone*
Address*
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County*
Email*
Gender*
How did you hear about us?
Full name of the person who referred you
More info
Please explain how you heard about us.

Education
- Some High School
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Employment*
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Political Affiliation
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Sexual Orientation
Marital Status*
Annual Household Income
Do you have Health Insurance?*
Do you Have Children?*
Country of Origin*
Ethnicity
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Occupation*

Which Type of Payment Card Do You Use?
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Check each that applies to you
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What Language to Primarily Use?
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Sex at Birth*
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If You Have any Health Conditions, Please List them Below
Do You Smoke Cigarettes?*
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Do You Drink Alcohol?*
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What is Your Favorite Brand of Alcohol?*
Select Each Non-alcoholic Drink You Consume*
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What Type of Cell Phone do You Use?*
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