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Address Please select one of the following options: We only send prescriptions directly to the pharmacy and don’t give them to the patients anymore.
Pharmacy Details:
If other please state name and address of the Pharmacy:
1.Drug Name: Duration of Drug 1: One MonthThree MonthsSix Months
2.Drug Name: Duration of Drug 2: One MonthThree MonthsSix Months
3.Drug Name: Duration of Drug 3: One MonthThree MonthsSix Months
4.Drug Name: Duration of Drug 4: One MonthThree MonthsSix Months
5.Drug Name: Duration of Drug 5: One MonthThree MonthsSix Months
6.Drug Name: Duration of Drug 6: One MonthThree MonthsSix Months
7.Drug Name: Duration of Drug 7: One MonthThree MonthsSix Months
8.Drug Name: Duration of Drug 8: One MonthThree MonthsSix Months
9.Drug Name: Duration of Drug 9: One MonthThree MonthsSix Months
10.Drug Name: Duration of Drug 10: One MonthThree MonthsSix Months
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Your name Address Please select one of the following options: We only send prescriptions directly to the pharmacy and don’t give them to the patients anymore. Pharmacy Details: If other please state name and address of the Pharmacy: 1.Drug Name: Duration of Drug 1: One MonthThree MonthsSix Months 2.Drug Name: Duration of Drug 2: One MonthThree MonthsSix Months 3.Drug Name: Duration of Drug 3: One MonthThree MonthsSix Months 4.Drug Name: Duration of Drug 4: One MonthThree MonthsSix Months 5.Drug Name: Duration of Drug 5: One MonthThree MonthsSix Months 6.Drug Name: Duration of Drug 6: One MonthThree MonthsSix Months 7.Drug Name: Duration of Drug 7: One MonthThree MonthsSix Months 8.Drug Name: Duration of Drug 8: One MonthThree MonthsSix Months 9.Drug Name: Duration of Drug 9: One MonthThree MonthsSix Months 10.Drug Name: Duration of Drug 10: One MonthThree MonthsSix Months Comment
