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Tel: +1 800 260 8919

Orlea Enterprise

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ORLEA ENTERPRISE

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Age*

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Diabetes types: *

Do you have any allergies? *

How long have you been diagnosed with diabetes?*

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When was the last time you saw your PCP?*

Any other significant medical condition.*

Hypertension

Heart disease.

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Foot ulcer

Kidney failure

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Please list any additional concerns or pertinent information.*

Tel: 800 260 8919

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