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* 1. What is your age?

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* 2. What gender do you identify as?

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* 3. What Race do you identify as?

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* 4. How did you hear about us?

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* 5. Who would use these services?

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* 6. How will you attend your appointments (i.e. travel to get to these services)?

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* 7. Do you have health benefits?

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* 8. What type of health/medical benefits do you have?

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* 9. Do you have a valid  Photo ID or License? 

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* 10. Do you own a Cellular Telephone/Tablet/Smart Device?

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* 11. How likely are you to use these services?

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