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01

Practice

02

Clinic contact

The person we set up the clinic’s account for and contact about it.

03

Prescriber

The licensed prescriber who will write orders. It can be the same person as the contact. Practices requesting telehealth prescribing support can choose “No prescriber yet”.

Are you, the contact, also the prescriber?
04

Practice address

05

How you work

Answer what you can. None of it is binding.

Do not include patient names, medication details, or other patient information.

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