Please take the time to answer the following questions so we can best accommodate your needs.

Name *
Have you had a seizure within the past 6 months? *
Have you been hospitalized or had an emergency room / urgent care visit in the past year? *
Are you on any prescribed medication on a permanent or semi-permanent basis? *
Are you allergic to any general medication (aspirin, sulfa, penicillin, etc.)? *
Do you have any food allergies? *
Do you have any other allergies? *
Have you ever been treated for diabetes? *
Do you have or have you ever had high blood pressure? *
Does any health element below apply to you?