Identifying Information

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* 1. What is your name (Last, First, MI)?

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* 2. At what email address would you like to be contacted?

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* 3. WHICH SHOULDER/CLAVICLE IS SERVICE-CONNECTED?

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* 4. RIGHT SHOULDER - Diagnosis EXACTLY as listed in your Rating Decision (or eBenefits, if known)

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* 5. LEFT SHOULDER - Diagnosis EXACTLY as listed in your Rating Decision (or eBenefits, if known)

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* 6. Which ARM do you consider your DOMINANT ARM

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