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Backtrace:

File: /home/site/wwwroot/application/controllers/Questionnaire.php
Line: 11
Function: _error_handler

File: /home/site/wwwroot/index.php
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Function: require_once

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Alnylam Assist® Copay Program Enrollment

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Severity: Warning

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Filename: views/questionnaire.php

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Backtrace:

File: /home/site/wwwroot/application/views/questionnaire.php
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Function: _error_handler

File: /home/site/wwwroot/application/controllers/Questionnaire.php
Line: 14
Function: view

File: /home/site/wwwroot/index.php
Line: 343
Function: require_once

A PHP Error was encountered

Severity: Warning

Message: Undefined array key "q3"

Filename: views/questionnaire.php

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Backtrace:

File: /home/site/wwwroot/application/views/questionnaire.php
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Function: _error_handler

File: /home/site/wwwroot/application/controllers/Questionnaire.php
Line: 14
Function: view

File: /home/site/wwwroot/index.php
Line: 343
Function: require_once

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Filename: views/questionnaire.php

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Backtrace:

File: /home/site/wwwroot/application/views/questionnaire.php
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Function: _error_handler

File: /home/site/wwwroot/application/controllers/Questionnaire.php
Line: 14
Function: view

File: /home/site/wwwroot/index.php
Line: 343
Function: require_once

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Filename: views/questionnaire.php

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Function: _error_handler

File: /home/site/wwwroot/application/controllers/Questionnaire.php
Line: 14
Function: view

File: /home/site/wwwroot/index.php
Line: 343
Function: require_once

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Filename: views/questionnaire.php

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File: /home/site/wwwroot/application/views/questionnaire.php
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Function: _error_handler

File: /home/site/wwwroot/application/controllers/Questionnaire.php
Line: 14
Function: view

File: /home/site/wwwroot/index.php
Line: 343
Function: require_once

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Severity: Warning

Message: Undefined array key "q8"

Filename: views/questionnaire.php

Line Number: 50

Backtrace:

File: /home/site/wwwroot/application/views/questionnaire.php
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Function: _error_handler

File: /home/site/wwwroot/application/controllers/Questionnaire.php
Line: 14
Function: view

File: /home/site/wwwroot/index.php
Line: 343
Function: require_once

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Severity: Warning

Message: Undefined array key "enrollee"

Filename: views/questionnaire.php

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Backtrace:

File: /home/site/wwwroot/application/views/questionnaire.php
Line: 51
Function: _error_handler

File: /home/site/wwwroot/application/controllers/Questionnaire.php
Line: 14
Function: view

File: /home/site/wwwroot/index.php
Line: 343
Function: require_once

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Filename: views/questionnaire.php

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Backtrace:

File: /home/site/wwwroot/application/views/questionnaire.php
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Function: _error_handler

File: /home/site/wwwroot/application/controllers/Questionnaire.php
Line: 14
Function: view

File: /home/site/wwwroot/index.php
Line: 343
Function: require_once

" class="img-fluid" width="25%">

Patient Information Form

Field is required
 
Field is required
Field is required
Field is required
Field is required
Field is required
Provide at least one contact number
At least one phone number is required
At least one phone number is required
Field is required