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HepaCare Membership Application
Name:
Sex:
M
F
Address:
Tel:
Email:
Occupation:
Date of Birth:
Y
M
D
How did you learn about Hepaguard
®
?
Newspaper
Magazine
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Pharmacies
Outdoor Ad
Pamphlets
Friends
Doctors
Reason of purchasing?
Hepatitis B Carrier
Chronic Hepatitis B
Liver Cirrhosis (fibrosis)
Liver Protection
Duration of Use:
1st time
1-3 months
4-6 months
7-9 months
>10 months
Liver Care
|
Hepatitis B
|
Join HepaCare
