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Nc memorandum form STATE OF NORTH CAROLINA County Name Of Plaintiff(s) File No. Film No. In The General Court Of Justice District Superior Court Division VERSUS Name Of Defendant(s) MEMORANDUM OF JUDGMENT/ORDER 1. The

Amp lab coat order form ucsf f... DATE: SCRUB & LAB COAT ORDER FORM NAME: PROGRAM: SIZING: All scrubwear is designed with a generous cut for comfort so keep this in mind when selecting a size. These scrubs are unisex, reversible

Printable t shirt form Order your 2013 WSU/Midian Shriners Car Show t-shirt --------------------------------------------T-Shirt Order Form-------------------------------------------Size: Adult $12.00 - M L XL $15.00 - XXL

Generic radiology order form RADIOLOGY OUTPATIENT ORDER FORM Attn: PATIENT - You MUST bring this form with you to the hospital. If you do not have this form, your Procedure will not be done. 501 Redmond Rd., Rome, Georgia (706)

Tshirt order forms jackson mic... TEAM T-SHIRT Jackson Parks, Recreation ORDER FORM and Grounds Department Requested By: Contact Number: Shirt Color: Ink Color: # # # # T-Shirts cost $8 each Make Checks Payable to: Jackson Recreation

Hoagie order formpdffillercom Bowser's Hoagie Order Form All items cost $6.00 All Hoagies include cheese (lettuce, tomato and onion on the side) *Special Comments* 18' Italian 18' Turkey Pepperoni Rolls 2 pack Silver

Getfantee form NAME ON BACK FUNDRAISER T-SHIRT ORDER FORM Cheerleaders are required to purchase a new one, but any fan can purchase one too! Monroe Wolverines Cheerleading FAMILY NAME: Please check size: Team Who

Outpatient lab order form merc... Outpatient Lab Order Form Patient Name Last First MI Mercy Lab Fax Number 641 428 7886 Birth Date Sex Collection Date Time Collected By / / Ordering Provider Consult Dr. Patient Location When Tests

Herbalife order form John Smith Independent Distributor 123 West Any Street Your Town CA 90502 t 123 456 7890 / f 123 446 7890 Invoice Date Invoice Name Ship To Phone Fax Email Address SKU Description Qty Unit Retail Price Notes Your Total Price Your Price Customer Loyalty Program Subtotal Tax Please Send Payment To Shipping Handling Total Due I understand that this order may be considered as an invitation to call upon me from time to time with the understanding that I will be under no obligation to buy. Important Notice You the buyer may cancel this transaction at any time prior to midnight of the third business day after the date of this transaction. See the Notice of Cancellation on the reverse of this form for an explanation of this right. After the three-day cancellation period provided above you are still protected by the HERBALIFE REFUND POLICY as set forth. John Smith Independent Distributor 123 West Any Street Your Town CA 90502 t 123 456 7890 / f 123 446 7890 Invoice Date Invoice Name Ship To Phone Fax Email Address SKU Description Qty Unit Retail Price Notes Your Total Price Your Price Customer Loyalty Program Subtotal Tax Please Send Payment To Shipping Handling Total Due I understand that this order may be considered as an invitation to call upon me from time to time with the understanding that I will be under no obligation to buy. Important Notice You the buyer may cancel this transaction at any time prior to midnight of the third business day after the date of this transaction* See the Notice of Cancellation on the reverse of this form for an explanation of this right. After the three-day cancellation period provided above you are still protected by the HERBALIFE REFUND POLICY as set forth. Page 1 of 2 Herbalife Refund Policy Herbalife offers an exchange or a full refund. Simply request a refund from your Distributor within thirty 30 days from receipt of your product and return the unused portion with the product containers to the Distributor named on the front side. Notice of Cancellation Date of Transaction / / You may CANCEL this transaction without any penalty or obligation within THREE 3 BUSINESS DAYS from the above date. If you cancel any property traded in any payments made by you under the contract or sale and any negotiable instrument executed by you will be returned within TEN 10 BUSINESS DAYS following the receipt of the seller of your cancellation notice and any security interest arising out of the transaction will be cancelled* If you cancel you must make the goods available to the seller at your residence in substantially as good condition as when received any goods delivered to you under this contract or sale or you may if you wish comply with the instructions of the seller regarding the return shipment of the goods at the seller s expense and risk. If you do make the goods available to the seller and the seller does not pick them up within twenty 20 days of the date of your Notice of Cancellation you may retain or dispose of the goods without any further obligation* If you fail to make the goods available to the seller or if you agree to return the goods to the seller and fail to do so then you remain liable for performance of all obligations under the contract.

Optumrx mail order form *6101* Medco Pharmacy MAIL-ORDER FORM 1 Customer information: Please verify or provide customer information below. Please send me e-mail notices about the status of the enclosed prescription(s) and

Avon order form Avon Order Form To place your order Contact Cindy 818-843-4405 Home 818-497-0883 Cell Name Catalogue Page Number Symons 818-843-4405 Fax upon Request Avonrepcindy yahoo.

Express scripts form Express-scripts. com/pa Fax completed form to 1-800-357-9577 If this an URGENT request please call 1-800-417-8164 Patient Information Prescriber Information Patient First Name Prescriber Name Patient Last Name Prescriber DEA/NPI required Patient ID Prescriber Phone Prescriber Fax Patient Phone Prescriber Address State Zip Code Primary Diagnosis ICD Code Please indicate which drug and strength is being requested 2. 5mg/24hr Transdermal System 1 Metered Dose Pump Transdermal Gel 1. 62 Metered Dose Pump Transdermal Gel 1 Transdermal Gel 30mg/actuation Topical Solution First- 2 Compounding Kit 10mg/actuation Transdermal Gel 30mg Buccal System 1 Topical Gel Other Directions for use i.e. QD BID PRN Qty Please complete the clinical assessment 1. Prior Authorization Form Topical This form is based on Express Scripts standard criteria and may not be applicable to all patients certain plans and situations may require additional information beyond what is specifically requested* Additional forms available www. express-scripts. com/pa Fax completed form to 1-800-357-9577 If this an URGENT request please call 1-800-417-8164 Patient Information Prescriber Information Patient First Name Prescriber Name Patient Last Name Prescriber DEA/NPI required Patient ID Prescriber Phone Prescriber Fax Patient Phone Prescriber Address State Zip Code Primary Diagnosis ICD Code Please indicate which drug and strength is being requested 2. 5mg/24hr Transdermal System 1 Metered Dose Pump Transdermal Gel 1. 62 Metered Dose Pump Transdermal Gel 1 Transdermal Gel 30mg/actuation Topical Solution First- 2 Compounding Kit 10mg/actuation Transdermal Gel 30mg Buccal System 1 Topical Gel Other Directions for use i*e* QD BID PRN Qty Please complete the clinical assessment 1. Does the patient have hypogonadism primary or secondary as confirmed by a low for age pre-treatment serum total or free level defined by the normal laboratory reference values Yes No N/A 2. Is the requested medication going to be used to enhance athletic performance endocrinologist the prostate 5. Is the patient 14 years of age or older AND the medication is being requested for the treatment of delayed puberty or induction of puberty 8. 27. 2013 7. Has the patient tried any of the following medications Are there any other comments diagnoses symptoms and/or any other information the physician feels is important to this review Prescriber Signature Date Office Contact Name Phone Number Based upon each patient s prescription plan additional questions may be required to complete the prior authorization process. If you have any questions about the process or required information please contact our prior authorization team at the number listed on the top of this form* physician* Only a treating physician can determine what medications are appropriate for the patient.

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