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Occupation & Job Duties

Have you ever used tobacco or nicotine products? If yes, please indicate what type. (Pipe, Cigar, Vape/E-Cigarette, Nicotine Gum, Patch, etc)

Please list any medications taken in the past 12 months (even those not currently taking, Name of Medication, Dosage, Frequency and Diagnosis)

Marie V. Berkey

(310) 383-1106
28004 S. Western Ave., Ste. 312
San Pedro, CA 90732