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Term period *
First Name *
Last Name *
Email *
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Are you a legal U.S. resident and have you resided in the U.S. for more than 2 years? *
YesNo
In the past 12 months have you used any form of tobacco, nicotine or nicotine products? If YES, Standard Nicotine rates apply. If NO, Standard Non-Nicotine rates apply. *
YesNo
Have you been diagnosed as having AIDS (Acquired Immunodeficiency Syndrome) or ARC (AIDS Related Complex) or tested positive for HIV (Human Immunodeficiency Virus)? *
YesNo
Are you waiting for a diagnosis or have you been advised to have a surgical operation, diagnostic test or medical or mental evaluation that has not yet been completed? *
YesNo
Have you requested or received any Worker’s Compensation or Social Security disability benefits? *
YesNo
Do you currently take more than 2 prescription medications for pain; or do you consume, on average, more than 3 alcoholic beverages per day? *
YesNo
In the past 10 years, have you received any treatment, medical advice or consultation for; been diagnosed with or required follow-up for: *
diabetes or elevated blood sugar; cancer (excluding basal cell or squamous cell carcinoma of the skin); stroke, transient ischemic attack (TIA or mini-stroke); emphysema; chronic bronchitis or chronic lung disease; major depression or anxiety that required psychiatric treatment; bipolar disease or mood disorder; schizophrenia, Alzheimer’s disease, dementia, rheumatoid arthritis, paralysis; any degenerative muscle or nerve disease or disorder; alcohol or drug abuse; OR any disease or disorder of the following: heart, aorta, coronary arteries, peripheral vascular system, blood, liver pancreas, kidney (other than kidney stones), brain or connective tissue?YesNo
In the past 2 years, have you been hospitalized or evaluated in an emergency room or immediate care center for a chronic illness requiring ongoing treatment or care by a physician; OR have you participated in any hazardous activities or extreme sports? *
YesNo
Have you, within the past 5 years, been convicted of or pled guilty or no contest to a felony, misdemeanor, reckless driving, DUI or DWI; or been incarcerated or served in a probation or parole program or do you have criminal charges pending *
YesNo
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