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* 1. First Name:

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* 2. Last Name:

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* 3. Do you live in Seminole County?

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* 4. Street address:

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* 5. Zip code:

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* 6. Phone number:

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* 7. Email address:

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* 8. Have you ever been told that you have prediabetes?

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* 9. Have you ever been told that you have diabetes?

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