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Name Of Pharmacy Original RX Filled
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MEDICATION NAME
Rx1 Med Name
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Rx3 Med Name
Rx Number
Rx 1 #
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Disclaimer:
The transmission of your refills online are completely secure and strictly follow our HIPPA privacy guidelines and laws.
I have reviewed the
Medstop Pharmacy Supplies
Notice of HIPPA Privacy Policy effective December 11th, 2010 and understand that all my medical information will be used by
Medstop Pharmacy Supplies
in strict accordance with this notice.
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