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md practice 50 rx initial order form

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FEE / FORMULATION APPROX COST # SUBTOTAL APPROX TOTAL: X I approve this order X I approve the implimentation fee X I approve the private insurance setup fee

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MD Practice 50 rx initial order form

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Page 1: MD Practice 50 rx initial order form

FEE / FORMULATION APPROX COST

# SUBTOTAL

APPROX TOTAL:

XI approve this order

XI approve the implimentation fee

XI approve the private insurance setup fee

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