Welcome! To be considered for the Zume Life Beta Test Program, please fill out this short form. Beta Test Program members must reside in the United States and have access to a regular phone line. We will ONLY use this information to help us select participants and communicate with you about the program. Thanks for your interest!

* Please tell us a little about yourself:

* Please provide your email address:

* Gender:

* Please tell us your age range:

* Are you a medical or health care professional?

* What on-going health conditions are you managing (please check all that apply):

* What are the biggest challenges you face in managing your health?

* How would you rate your control of your health?

* How would you rate your own ability to manage your health?

* How informed are you about your condition and treatments?

* How many prescription medications do you take every day?

* How many non-prescription medications do you take every day?

* How many vitamins and/or supplements do you take every day?

* How did you hear about the Zume Life Beta Program? (Please check all that apply)

* What interests you about Zume Life?

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