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Home > Alternative Treatments > Practitioner Pages > Suggested Liver Extract Order Form
Suggested Liver Extract Order Form Print E-mail

Click Orange PRINT Icon & FAX to 630-859-0114

 

RX: Compounded Liver Extract #10ml
Instructions: Inject 0.5ml IM four times a week (Mon Wed Fri Sun). May be mixed with thiamine in same syringe.

Quantity of Months Prescribed:   #_________          -             Refills: ______


Doctor Signature: _____________________________      Date: ___/___/____

 

Patient Name:
Patient Phone:
Patient Address:
City/State/ZIP
Doctor Name:
Doctor Phone:
Doctor Address:
City/State/ZIP
DEA#:
License Number:
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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