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Get Viverae Physician Screening Collection Form

____/______/______ TEST PARAMETER Total Cholesterol HDL Cholesterol LDL Cholesterol Triglycerides Glucose Systolic Blood Pressure (rest) Diastolic Blood Pressure (rest) Height Weight Waist Circumference VALUE UNITS mg/dL mg/dL mg/dL mg/dL mg/dL mmHg mmHg ft/in lbs in FASTING: YES / NO 888-VIVERAE (848-3723) :: 10670 N. Central Expressway, Suite 700 :: Dallas, TX 75231 :: www.MyViverae.com .

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