These questions are to help determine if the potential donor would be a good candidate for tissue donation. These questions will cover topics such as medical history, past surgeries, past diseases, drug use, and highrisk sexual behavior. Please answer the following questions to the best of your knowledge. Answer the questions with a yes or no. If the answer is yes, please explain your response in the space provided. Please note, we are only accepting in Arizona and Florida at this time.

Question Title

* 1. Does potential Donor reside in Arizona or Florida

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