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By submitting this form I expressly represent, warrant, and agree that I am over 21 years old, that no protected health information, as that term is defined in HIPAA, of either me or any third party is or will be provided, that if I request medical information I certify that I am a physician or healthcare provider, that my personal information may be used by Adaptive for sales and marketing and other purposes, and that the terms of the Adaptive Online Privacy Policy, Terms of Use, HIPAA Policy, and any other Adaptive policies apply.

I AGREE * Yes

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