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Get Patient Assistance Program

I understand that the Patient Assistance Program has the right to modify or discontinue this program and its eligibility requirements or to terminate assistance at any time and without prior notice. Please return a copy of this signed form along with the completed Qualification application form to the Patient Assistance Program 2008 Duramed Pharmaceuticals Inc. PPAPPAD October 2008 Paraguard262088W 6/9/06 1 57 PM Page 1 FLAT SI.

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