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MUST CHECK ONE Zip: Ground 2nd Day PATIENT INFORMATION Name: DOB: Address: City: Phone: State: Zip: Email MUST CHECK ONE: Patient will pick-up at pharmacy 503B Label PGE1 PGE2 PGE3 BM3 T-50 NB-143 NB-243 NB-343 T-101 T-105 T-106 SB4 SB5 SB6 ST2 RE1 RE2 FormF1 QM1 QM2 QM3 QM4 FormF9 FA Dispense Qty: Papaverine mg/ml Phent. mg/ml Ship to patient address PGE mcg/ml mg/ml 40 80 150 30 8 30 30 30 17.65 30 30 30 30 30 30 30 30 1.8 30 30 30 30 0.9 20 2.5ml 5ml 3 0.29.

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