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GERD / Heartburn Patient Questionnaire

If you have heartburn or GERD or take medications for those conditions, please complete this GERD Health Related Quality of Life questionnaire.
  • Please enter your first name.
  • Please enter your last name.
  • This isn't a valid phone number.
    Please enter your phone number.
  • This isn't a valid email address.
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*We will call you within two business days. Sorry, we cannot provide a diagnosis or treatment by email. If this is a medical emergency, call 911 immediatly.