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Patient Refill Questionnaire

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Experienced any issues with injection site or side effects?*
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Bleeding and Missed Doses

Bleeding and Missed Doses

Have you had any E.R. or urgent care visits since your last prescription fill?*
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Have you had any bleeds since your last refill?
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Have all the bleed resolved?*
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Have you missed any doses?*
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Supplies and Changes

Supplies and Changes

Additional supplies needed
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Have there been any changes to your current medications or allergies?*
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Would you like the pharmacist to call you?
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By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

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