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* 1. Who is your primary insurance provider?

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* 2. Did you apply for insurance reimbursement for your DigniCap treatments?

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* 3. How did you file?

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* 4. If you were reimbursed by your insurance provider, what approximate percentage or dollar amount did you receive?

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* 5. On a scale of 1-10, how satisfied were you with your DigniCap experience?

0 - Not Satisfied 10 - Extremely Satisfied
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i We adjusted the number you entered based on the slider’s scale.

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* 6. Your Information

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