What is your age?

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* 1. What is your age?

Are you male or female?

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* 2. Are you male or female?

How did you find out about this clinic?

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* 8. How did you find out about this clinic?

What other services would you like to have available at this clinic?

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* 9. What other services would you like to have available at this clinic?

COMMENTS:

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* 10. COMMENTS:

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