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Get Ak Tuberculosis Prescription/medication Request Form 2018-2025

Cycle ***Expedited Shipping requires Epi approval, Overnight Shipping Approved by: Patient Last Name: Weight: kg Patient First Name: HR# MALE DOB: FEMALE and PREGNANT OR BREASTFEEDING (CHECK ONLY IF APPLICABLE) Projected Start Date: No Known Allergies OR List Allergies: Medications taking (including OTC s): New Medication Request Modification of Existing Medication Order Doses given from STOCK: Dispense in: Bottles OR English Medication Info Sheet or other: Unit Dos.

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