Raw Score for this Application:  out of  - % <br /><br/>Q1. Please enter the following: First Name, Last Name  <br/><b>Name:</b>  <br/><br />Q2. Please enter the following: Email  <br/> Email:<input type="text" name="email" value="" size="40" /><br/>  <br />Q3. R.E.A.L. will protect your information. Information is only used as is reasonably necessary to process your application or to provide you with health or counseling services which may require communication between HHSN and health care providers, medical product or service providers, pharmacies, insurance companies, and other providers necessary to verify your medical information is accurate and determine the type of medical supplies or health care services you need.  <br/><input type="radio" id="3999" value="3999" name="3" checked=""> <label for="3999">  YES, I Agree for R.E.A.L to use my Information  </label><br />
    <input type="radio" id="4000" value="4000" name="3" checked=""> <label for="4000">  NO, I do not agree  </label><br />
    <br />Q4. Phone Number:  <br/> <br/>
      <br />Q5. Age:  <br/> <br/>
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