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Plete FOR HCP TO COMPLETE AND SIGN Be sure to check the appropriate doses the patient k should receive in the top portion of this form Prescriber s Information Prescriber Name* Prescriber Address Check One: City State Name* Phone* Fax* Treatment of Patient*: Dose: MD DO Other: NPI # ZIP is given as a subcutaneous (SC) injection 40 mg every other week Qty: Direction: My signature on this Enrollment Form indicates I am requesting a Registered Nurse to either (i.

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