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X 1-888-773-0121 PO Box 220574 Charlotte, NC 28222-0574 Please check the appropriate Pfizer product (For full prescribing information, go to www.pfizer.com) ( mesylate) ( mesylate) () () () (silendafil citrate) Has the Tropism assay been completed? Patient Name: Sex: Yes Male No Female Patient Address: City: Telephone (Day): ( ).

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