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Health Care Survey Health Care Survey

What is your first name? *
What is your last name? *
What is your e-mail address? *
Please confirm your email address. *
What is your phone number? *
Do you believe there is a health care crisis in America?
Do you have dental benefits? *
Do you have medical benefits? *
Are you making all the money you can spend? *
Do you have 5 or more employees/independent contractors?
Who referred you? (Name & email.)

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