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Entyvio in Canada Pharmacy  Form

Entyvio in Canada Pharmacy Form

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Height:_________ Diagnosis:________________________________________________________________________________ DX CODES: ICD-10 : ______________________, _______________________, ____________________ TB verification (circle one): TB skin test Result Date: ________/_______/__________ LABS to be drawn: Pre- Medications: (Not Indicated) TB spot blood test Chest X-RAY Result (circle one):  CBC  CMP  ________ Positive  COPY ATTACHED Negative Lab Frequency:...
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