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Name
*
Your answer
Phone no.
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Your answer
Delivery Postal Address
*
Your answer
Indicate your type of Lactose Intolerant.
*
Primary
Secondary
Congenital
Developmental
Can you tolerate a small amount of dairy products? e.g. Milk, cheese, etc.
*
Yes
No
Describe what happens when you experience lactose intolerant symptoms.
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Your answer
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