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Patient Assistance Program Product Request Form For physician use only. Do not post online or allow patients to complete this form. PHYSICIAN INFORMATIONPATIENT INFORMATIONPhysician NameFirst Pataphysician

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Obtain a 'Do Not Post Online' sticker or label.

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Individuals or organizations who want to maintain their privacy and prevent certain documents or items from being shared online.

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Do not post online refers to information or content that should not be shared or published on the internet.

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