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To the next page to read and sign the Patient Agreement and Consent. Page 2 of 4 NOUS14UB02147-01 October 2014 Patient Agreement and Consent By signing below I promise that All of the information I provided in this sign-up form and the copies of the income documents or other information about me that I may provide are complete and true. If I am approved to get free medicine enrolled I agree to not get reimbursed for the free medicine from anyone else including from a prescription insurance...
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