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The following orders will be implemented per physician order of this protocol. Orders with and are indicator choices and are NOT implemented unless checked. Initial the bottom of each page when indicated

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6. Next, provide any additional information requested on the form, such as your marital status or citizenship status.
7. Carefully review the completed form to ensure all the information is accurate and complete.
8. Once you have verified the form, sign and date it at the designated space.
9. Submit the filled-out form as instructed, either by mail, in person, or through an online submission portal, if available.
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The initial form bottom of is a document that serves as the foundation for further evaluation and analysis.

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