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Dental, Pharmacy, Professional Licensing Quarterly Report - Participant Form

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Quarterly Report - Participant Form

Indicate which quarter this report covers:

Did you experience any suicidal ideations this past quarter?

Do you have any plans to travel during the quarter coming up? If yes, please provide details below.

Have you experienced a return to use during this quarter?

Do you have any questions for the IPHP staff?

Your Signature:

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Today's Date: