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Complete Name

Email

Phone Number

Please tell us where are you from? (Country and Province/State)

Please tell us about the treatment(s) you are having with Dr. Flikier

In the next visit, would you like to visit Costa Rica with someone? (Example: Husband, Wife, Friend, etc.)

In what Solved Costa Rica Package are you interested in? In what Solved Costa Rica Package are you interested in?Standard PackagePremium PackageDeluxe Package

Do you have any food allergies? Do you have any food allergies?YesNo

If you have any food allergy, please tell us the ingredient(s) (Example: Egg, Strawberries, etc.)

Are you allergic to any medicine or treatment? Are you allergic to any medicine or treatment?YesNo

If you had any allergic reaction before please tell us the trigger or triggers

Do you have any special ingredient you love?

Do you have any ingredient(s) you don't like? Or for any reason you avoid?

Please tell us your favorite color

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