OPT-IN FOR THE #FASTPAINRELIEFSA TRIAL TEST WITH DEEP RELIEF!

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* 1. Personal Information

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* 2. Your age bracket:

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* 3. Your gender:

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* 4. Your race:

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* 5. Is your delivery address in an outlying / remote area that is not close to a main city area? (Township, farm, out-of-town etc.)

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* 6. Do you suffer from pain?

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