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Personal Experience Information Form


Please be assured that Cforyourself will keep your personal experience and all other information strictly confidential.  We will use this information for tracking and tabulation purposes, but will not attach individual's identities to the resultant information.  We will ask you first before giving anyone your name or any other personal information.  Since we are so new, I don't know what might come up, so as of right now, please understand that you have NOT given ANY permission to disclose any information to other parties that is tied to your identity.  Please e-mail me if you have any questions.

While not necessary, we would appreciate your personal contact information so that we may communicate with you personally if we have any questions and to follow-up on your experience.

Thank you.

 

Contact Information
 

 

Your First Name:


 

Your Last Name:


 

Your email address:

 

 


Would it be all right to contact you by phone?

Phone number w/area code:

 

 

Personal Information
 

 

Date of Birth:


 

Gender:

  Male  Female


Area of Vitamin C Experience:


 

 

Medical Information
 

 

Date of First Diagnosis:
 

 

Date of First C Usage:
 

 

How Much C Do You Take?
 

 mg per day

 

Please explain your experience with this disease (if Other, please explain) and how vitamin C has helped:

 


If you found C For Yourself  from a search engine, please tell us which one



 

Did you use a search phrase ?

 


 


 

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