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5ml CLINICAL 20mg/2ml One 48mg/6ml 16mg/2ml Other Health Conditions Prescriber s Office Other QTY PRESCRIBER Primary Phone New Prescription Refill Prescription New to Therapy Restarting Therapy Patient s Home 20mg/2ml / MEDICATION Sex DIRECTIONS Inject 2ml IA into affected knee s at weekly intervals for 3 weeks. SIGN AND FAX THIS FORM TO 877. 828. 3939 If you have questions please call 877. 627. MEDS 6337 Prime Specialty Pharmacy NPI 1457618555 OSTEOARTHRITIS REFERRAL FORM PATIENT INFORMATION...
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