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2. First Name (of person filling out form)*
3. Last Name (of person filling out form)*
5. Phone Number*
6. Can receive text messages?

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7. Email
9. Preferred day of the week to be contacted:
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10. Preferred time of day to be contacted:
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12. By submitting this form, I consent to be contacted by the Livingston County Department of Health.
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14. 1. Receive an email copy of this form.
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