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Get Allergan Patient Assistance Program Fax Transmittal Sheet 2009-2022

________________________________ Date: __________________________________ Phone: _______________________________ Number of pages including cover: _________ Re: ___________________________________ Re Patient: _____________________________ Application MUST FAX or MAIL completed application with income documentation to the address above. Healthcare Provider and Patient MUST sign the application. Patient MUST provide a Social Security Number. Patients at or below 200% of the current Federal Po.

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