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HepaCare Membership Application
Name: Sex: MF
Address:
Tel: Email:
Occupation: Date of Birth: YMD
How did you learn about Hepaguard?
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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

 
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