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KIDD AND ITP PRESCRIPTION REFERRAL FORM Please fax completed form to 18557107035 PATIENT INFORMATION: Name:Date of birth:Address:Height:City:State:Phone:ZIP://(ft/in)Male Weight:FemalelbkgDiagnosis

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How to fill out please fax completed form

1. Begin by gathering all the necessary information and documents for the form.
2. Make sure you have access to a fax machine and the completed form is ready.
3. Dial the fax number of the recipient and wait for the connection to be established.
4. Once connected, carefully place the completed form into the fax machine's feeder tray.
5. Double-check that the form is aligned properly and not wrinkled or folded.
6. Press the appropriate buttons on the fax machine to start the transmission.
7. Wait for the fax machine to complete sending the form, ensuring that all pages have been successfully transmitted.
8. If required, record the confirmation or receipt number provided by the fax machine.
9. Keep a copy of the completed form for your records, if necessary.
10. Confirm with the recipient that they have received the faxed completed form if needed.

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