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* 1. What primary condition are you interested in receiving information for?

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* 2. Have you reviewed our list of Frequently Asked Questions?

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* 3. One a scale of 1 to 5, how familiar are you with the safety research we presented on your condition?

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* 4. On a scale of 1 to 5, how familiar are you with the efficacy research we presented on your condition:

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* 5. Are you aware that stem cell therapy procedures on average can cost between $10,000 - $20,000?

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* 6. Are you aware that the therapeutic effects of stem cell therapy may take weeks or months to become evident, and that the degree of these effects are not guaranteed?

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* 7. Are you aware that despite a significant amount of research demonstrating safety and efficacy, most stem cell therapies are not FDA approved?

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* 8. How interested are you in receiving stem cell therapy?

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* 9. What is your name?

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* 10. What is your email address?

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