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Ture of person legally authorized to sign for patient/relationship 4. STELARASUPPORT EXTENDED SERVICES ENROLLMENT (To be completed by a patient who wishes to enroll for Extended MAINTENANCE THERAPY REQUESTED SHIP DATE 1 single-use prefilled syringe; 45 mg SC every 12 weeks Refills # 1 single-use prefilled syringe; 90 mg SC every 12 weeks Refills # PRESCRIBER SIGNATURE (NO STAMPS ALLOWED) REQUIRED TO VALIDATE PRESCRIPTION: I certify that therapy with is medically necessary.

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