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  • English (US)
  • Medication Declaration

  • Please complete all parts of this form and then press the SUBMIT button:

    • You will be required to enter all of your medications
    • An e-mail address is required
    • A copy of your submission will be sent to you for your records
    • You will receive a reminder when your next declaration is almost due 
  •  -  - Pick a Date
  • If you continue to take your medication,  you will be required to re-enter all of your medications one month from the date shown below

  •  -  - Pick a Date
  • Please add your e-mail address and mobile phone number below to recieve a copy of this submission straight to your inbox.

    You MUST PROVIDE an e-mail address to recieve reminders as this is part of a verification process to send you information. If you do not add an e-mail address you WILL NOT BE ABLE TO COMPLETE YOUR MEDICAL DECLARATION

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