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First Name*

Last Name*

Phone*

e.g. 555-555-5555

Email*

Have you been prescribed Suboxone film?*

Yes

When did you start taking Suboxone film?*

Did you take Suboxone film for at least 6 months?*

Yes

Have you experienced tooth decay, tooth loss, broken teeth, or extractions?*

Yes

When did you first experience tooth decay, tooth loss, broken teeth, or extractions?*

When would be a good time to call you?

Central Time

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I Consent