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For
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Address
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City, State and Zip
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Phone
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DOB: (auto generated)
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Date
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Rx
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Sig:
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Disp:
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Refills:
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Indication:
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Note to Pharmacy
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Allow Generic Subsitution
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Signature:
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John Chrono, M.D.
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Joanna Chrono, PA-C
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Return Address
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