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TELEMED SCHEDULING FORM

In order to receive your purchases, you must fill out the Personal Information Form below and submit it to BiocoreHealthRX. We will assess and document the form and schedule a Telemed Appt with a Physician within 24 hours. After approval from the physician, your purchases will be released for shipping to you.
Enrollment Form

Personal Information

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Spouse/Significant Other or Next of Kin

Medical History

Any history of the following (continued)

INTERNAL USE BELOW THIS POINT - DO NOT FILL OUT

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