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INFLECTED (INFLIXIMABDYYB) ORDER FORM: 877.365.5566 | F: 855.889.2946 PATIENT INFORMATIONDemographics attachedPatient Name: ___ DOB: ___ Phone: ___ INSURANCE INFORMATION: PLEASE ATTACH COPY OF PRESCRIPTION/MEDICAL

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Q code q5103 is a specific code used for reporting a certain type of information to the relevant authorities.

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