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The prescription is to be dispensed as written unless otherwise instructed by me. Prescriber Signature Prescriber Full Name State License DEA Office Contact NPI Prescriber Specialty Credit Card Number Expiration CVC/Code FAX FORM TO 949 551-1950 Billing Zip. Prescriber Verification I have reviewed my patient s medical record and determined the medication s / supplies ordered are medically necessary. Please deliver to with this cover sheet to protect its contents. ImprimisRx Order Form Order...
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