HFORM

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To properly direct you to the correct questionaires, please tell us gender
Please Select
Please Select
Male
Female
Other
2
Age Group
0-18
19-44
45-64
65-84
85 and over
3
General and Respiratory Symptoms (Check if Present)This checklist highlights the top 5 symptom categories associated with Long COVID. Each category includes key symptoms to help you track your condition. Use this tool to discuss symptoms and their impact with your healthcare provider.
Persistent fatigue
Post-exertional malaise (worsening after activity)
Shortness of breath
Chronic cough
4
Neurological Symptoms Check if Present
Difficulty concentrating ("brain fog")
Memory problems
Sleep disturbances
Recurring headaches
Lightheadedness or dizziness
5
Sensory SymptomsCheck if Present
Loss or change in sense of smell
Loss or change in sense of taste
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Indicate how much Long COVID symptoms have impacted your daily lifeNo Impact(1) Mild Impact(2) Moderate Impact(3) Severe Impact(4)
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Work or employment
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School or education
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Caregiving responsibilities
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Daily self-care or independence
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Physical activities or exercise
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Work or employment
School or education
Caregiving responsibilities
Daily self-care or independence
Physical activities or exercise
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Row 0, Column 0
2
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3
Row 0, Column 2
4
Row 0, Column 3
1
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1
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Have you taken any of the following medications in the past 24 hours?
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
Albuterol
Ipratropium
Budesonide
Cetirizine
Famotidine
Ivermectin
Other
Albuterol
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
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Based on the data we gathered from your input, you maybe benefit from the diagnotic test.
Companion diagnostic test (IncellKINE™)
10

Great! We will gather and create an order for you at the end of this form.

Your order will be submitted at the end of this form after your payment.
Our partner will follow up.
11
Product Offering - Long Covid
YesNo
YesNo
Are you interested in our Patented companion diagnostic test (IncellKINE™)
Are you interested in our Patented combination therapy
Are you interested in our Patented companion diagnostic test (IncellKINE™)
YesNo
YesNo
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Do you know anyone struggling with long COVID or experiencing the challenges of post-acute sequelae of COVID? If you know someone who could benefit from our support, we’d love to help! We’re always here for your referrals. Please feel free to share their name and contact information with us.
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Name
First Name
Last Name
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Email
example@example.com
15
Phone NumberOptional
Area Code
Phone Number
16
My Products
prevnext( X )
My Bag
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My Bag
Great Product Name
$20
Quantity:1
Size:Small
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Great Product Name
$20
Quantity:1
Size:Small
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Great Product Name
$20
Quantity:1
Size:Small
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Great Product Name
$20
Quantity:1
Size:Small
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ORDER SUMMARY
Total costUSD
Companion Diagnostic Test (IncellKINE™)Enter description
$460.00Edit
Back
1
1
2
3
4
5
6
7
8
9
10
Quantity
Combination Therapy
$560.00Edit
Back
Total cost $0.00
Credit Card
First Name
Last Name
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Terms and Conditions* This field is required.
Should be Empty:

Great! We will gather and create an order for you at the end of this form.Your order will be submitted at the end of this form after your payment.Our partner will follow up.

Great! We will gather and create an order for you at the end of this form.

Your order will be submitted at the end of this form after your payment.
Our partner will follow up.