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RIA Shop Request

Please send back to for processing

MM slash DD slash YYYY

Medical History:

Medications within the last 5 years?:(Required)
Reason for previous decline/rating (including family history):(Required)
Tobacco/Nicotine/Marijuana Use within the last 5 years:(Required)
MM slash DD slash YYYY
Any additional details regarding significant medical history/tests completed:(Required)

Additional Forms/Information:
**The Part 2 completed by the client with the MM app usually has all the above as well as any significant medical history that we would need to include in a shop.**
** If due to lab results, we would need to see a copy of the completed labs or provide the abnormal values**