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Referring Clinic Name STEP 1 PATIENT SECTION Patient Name Date // mm dd yyyy Date of Birth // Patient ID/SSN mm dd Patient Address City State Zip Annual Household of People Phone Income in Household M F Food/Medications you are allergic to Other Medications you are taking and Medical Conditions Shipping address if different from above Name Address City State Zip PLEASE NOTE THAT CONTROLLED SUBSTANCES CANNOT BE SHIPPED TO A P. O. BOX OR DOCTOR S.

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