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Bioweapon Recovery
Booking Form
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First Name*:
Last Name*:
Email*:
Phone*:
Gender*:
Male
Female
Age*:
Body Weight*:
Profession or former profession*:
What brand of vaccine was administered to you (Pfizer, Moderna, Astra Zeneca, etc)*:
One shot, two, or two plus followup boosters?*:
Approximately how long ago was the last one?*:
What symptoms have you been experiencing since you received your shots or boosters?*:
Any co-morbidities (pre-existing health conditions that could have been worsened as a result of the vax) or any other details you would like to share with us:
I acknowledge that the patient is able to walk and eat.
How did you hear about us?*:
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