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FazaClo Patient Registry Healthcare Practitioner Enrollment Form Instruction This form is used to enroll a health care practitioner in the FazaClo Patient Registry. I agree to prescribe FazaClo only after verifying patient rechallenge status and an acceptable baseline WBC count 3500/mm3 and ANC 2000/mm3 test results and only after receiving a Patient Registration Number PRN from the FazaClo Patient Registry. All forms must be signed a.

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