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Smart Medical - Wound Care (Google)
HIPAA
Compliance
1
WHAT IS YOUR MAIN CONCERN?
*
This field is required.
SELECT ONE
ARTERIAL WOUNDS
VENOUS LEG ULCER
DIABETIC FOOT ULCER
SACRAL ULCERS
PRESSURE ULCERS
BURNS
SURGICAL WOUNDS
SOMETHING ELSE
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2
HOW LONG AGO DID THIS HAPPEN?
*
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SELECT ONE
TODAY
1-7 DAYS AGO
1-4 WEEKS AGO
1+ MONTH AGO
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3
DO YOU HAVE A MEDICARE POLICY?
*
This field is required.
SELECT ONE
YES
NO
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4
WHAT IS YOUR NAME?
*
This field is required.
ENTER FIRST & LAST NAME
First Name
Last Name
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5
WHAT IS YOUR EMAIL ADDRESS?
*
This field is required.
ENTER EMAIL ADDRESS
example@example.com
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6
Terms and Conditions
*
This field is required.
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7
WHAT IS YOUR PHONE NUMBER?
*
This field is required.
ENTER PHONE NUMBER
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8
Sender
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