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658 90 day supply is preferred Note: Schedule II medications cannot be faxed Patient's Name: Sex (circle): Date of Birth: Insurance ID #: Shipping Address: Phone Number: City: Zip: State: Drug Allergies: None Known Others: Health Conditions: High Blood Pres. Cephalosporins Alternate Phone Number: Diabetes Arthritis High Cholesterol Asthma Thyroid Disorder Cancer Others: Heart Condition Sulfa Aspirin Glaucoma Codeine Tetracyclin.

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