Thank you for completing the survey. Once it's complete, we'll send you your complimentary Provider Kit and any additional materials you request.

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* 1. Name: 

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* 2. Email: 

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* 3. Practice name and location (city and state):

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* 4. After this survey, we will send you the provider kit with prescribing instructions. Please let us know what additional materials you would like us to send. Select all that apply:

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* 5. What address should we send the kit and other requested materials to?

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* 6. Thank you!  We will send you updates periodically and will be in contact once we are FDA approved.  Please note here if:
- You have any additional comments.
- You would like to be contacted about investing in YoniFit.
- You would like to be contacted for any other reason.  
Thank you for your time and we look forward to sharing our product with you.

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