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Note This form is intended for prescriber use only. If faxed the fax must come from an MD office or hospital should not be faxed by patient Crohn s Disease / Ulcerative Colitis Prescription/Pharmacy Intake Form Select one of our Central Pharmacy numbers from the drop downs below or type a Retail/Community Pharmacy number in the blank space provided Rx Phone Rx FAX Provider Representative Phone Date Needed Ship to Specialty Care Center Prescriber s O ce Patient s Home Other PATIENT INFORMATION...

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