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Get Pfizer Fillable Application Form

X 1-888-773-0121 PO Box 220574, Charlotte, NC 28222-0574 Please check the appropriate Pfizer product: () Antihemophilic Factor (recombinant), Plasma/Albumin-Free () BeneFIX Coagulation Factor IX (recombinant) ( citrate) () ()* * Reimbursement Services Only Patient Name: Sex: Male Female Patient Address: E-mail: City: Telephone (Day): ( ).

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