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Q Bilateral Phone: q Left q Right Phone: 1 Wound Care Center: q Patient has been notified of and chosen MPCS for this order 2 1 8 Patient s Preferred Language q English q Spanish q Other 2 9 FAX COMPLETED FORM AND COMPRESSION PUMP PRESCRIPTION TO MPCS AT 1-800-749-0711. Patient Medical History 1. oes the patient have open wound(s)? D If yes, what length of time? Are wounds draining? 3 8 3 q Yes q No q 6 months q Longer q Yes q No 4 7 How often do.

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