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Get FRMALP101 2005-2024

STRUCTIONS BELOW : 1. Enclose a 30 day valid prescription for ® C-II ( Sulfate Sustained Release) Capsules 2. Include a money order for $5.00 payable to Alpharma (to cover the cost of shipping and handling) 3. Attach Proof of Income (Acceptable documentation include IRS Form 1040, 1040EZ, 4506T, 1099, social security or disability statement, etc.) SECTION 1 PHYSICIAN INFORMATION Physician Name DEA # Address City Office Phone Number ( State ) What is your specialty? (required.

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