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Get Telepain Medicine Form

TelePain Case Consultation Request Form UW Medicine Pain Medicine Please complete ALL ITEMS on this form and fax to Cara Towle at 206-598-4576 Provider First Name Provider Last Name Provider Phone Number for phone follow-up Provider email Provider Fax Number where medical records follow-up can be sent Clinic/Facility Name TelePain Chronic Pain Clinic is on Wednesdays 12-1 30 pm. On which Wednesday 1st and 2nd choice would you like to present the .

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