* 1. Please enter your contact information.

* 2. What is your gender?

* 3. What is your date of birth?

Birth Date
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* 4. Have you been diagnosed with celiac disease or gluten sensitivity by a licensed physician?

* 5. Are you a caregiver for someone diagnosed with celiac disease or gluten sensitivity by a licensed physician?

* 6. Please provide the birthdate for each patient you care for.

Birthdate
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Birthdate
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Birthdate
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Birthdate
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* 7. What was your age of diagnosis?

* 8. Please provide the age of diagnosis for each patient you care for.

* 9. Please provide any additional information you would like us to know. 

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