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Ly as possible, please follow the instructions outlined below. We appreciate your referral and look forward to working with you and your patients. Order Instructions*: 1. Complete all sections of this form. Please note, this form serves as an official order and must be fully completed and signed by the patient s medical provider. Incomplete or illegible forms or forms submitted without an official signature will be returned for completion. 2. Fax page 2 of this form to 859-257-9843 (do not f.

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