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Date Shipment Needed:Phone: 877.291.1122 Fax: 877.291.1155.TAFTA REFERRAL FORMATION INFORMATION Patient Name: DOB: Sex: M F Weight: lbs. kg. SSN: Phone: Allergies: Address: City: State: Zip: Emergency
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1122 fax 877 is a form used for filing tax information with the IRS.
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