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First Name*

Last Name*

Phone*

e.g. 555-555-5555

Email*

Have you or a loved one taken Valsartan?*

Yes

No

Have you or a loved one been diagnosed with any of the following resulting in hospitalization?*

Liver cancer

Esophageal cancer

Colorectal cancer

Small Intestine

Stomach cancer

Pancreatic cancer

None of the Above

When would be a good time to call you?

Central Time

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I Consent