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Base-12 Code
Encryption Hub
RASHA Upgrade Client Form
First Name
Last Name
Email
Do you have a Pacemaker?
Yes
No
Are you currently undergoing chemotherapy or radiation treatments?
Yes
No
Do you have a history of seizures?
Yes
No
What are you hoping to address with your RASHA upgrades?
Your Signature
Clear
I declare that the information I’ve provided is accurate & complete.
Submit
Thanks for submitting!
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