Click Orange PRINT Icon & FAX to 630-859-0114
Please circle the correct Naltrexone strength:
3.0mg 4.5mg ____mg
Quantity of Capsules: #_________ - Refills: ______
Instructions: Take 1 capsule at time of sleep
Doctor Signature: _____________________________ Date: ___/___/____
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Product costs do not include shipping and handling fees. Shipping will be added prior to charging.
Please print & FAX to 630-859-0114
All information will be verified prior to processing.
All patient information is considered confidential and is to be released only to authorized personnel, as delineated by HIPAA.
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