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Pharmion . Prescriber First Name: Prescriber Last Name: Signature: Date: DD MM YYYY Note to pharmacist: the date of the prescription must match the date on this prescription authorisation form. Pharmacy Con rmation I am satis ed that the Pharmion prescription authorisation form has been completed fully, con rm that dispensing is taking place within 7 days of the prescription date, and within 10 days of the negative pregnancy test date. I have read and understood the.

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