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Enrollment Form
First name
*
Last name
*
Phone
*
Birthday
*
Month
Month
Day
Year
Medicare ID #
*
Do you have high blood pressure?
*
Yes
No
Are you diabetic?
*
Yes
No
Are you interested in free COVID-19 testing?
*
Yes
No
Do you have any allergies?
*
Yes
No
Do you any of the following assistive devices?
*
Wheelchair
Walker
Cane
Not Applicable
Other
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