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Get Wyeth Refill Form

S section out completely! Your medication order may be shipped to your health care provider s office or your home. DATE NAME LAST PATIENT S SOCIAL SECURITY NUMBER MI FIRST DAYTIME PHONE ) HOME PHONE STREET MAILING ADDRESS ( ( ) HEALTH CARE PROVIDER S NAME APT. NO. ZIP CODE STATE CITY HEALTH CARE PROVIDER S PHONE ( ) I acknowledge that the information on this form is true and correct. I certify I do not have the ability to pay for my medication, earn less than 200% of the c.

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