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Get Fax 800 266 2065

Age: Address: City: State: Home Phone: Work Phone: Please enroll this patient in the ScriptAssist patient support service. Zip: Cell Phone: Special Instructions (Non-English Speaking, Name of Guardian, etc.): 2 Prescription Pad Depot ( acetate for depot suspension) Urology/Onc Products 22.5 mg (3 month dose) Pediatric Products 11.25 mg PED (4 week dose) / PHYSICIANS SIGNATURE (REQUIRED) / DATE DEA# Check one dosage: Gynecology Products 3.75 mg (1 month dose).

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