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Medication Request Information

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• Drug Name(s)*

  

• Dosage Strengths(s)*

  

• • Dosage Form *

    --Select-- Capsule Tablet Mini Tablet Oral Solution Oral Suspension Chew Treat Troche Oral Powder Topical Cream Topical Ointment Transdermal Gel Suppository Otic Polox-A-Gel Otic Ointment Otic Drops Ophthalmic Ointment Ophthalmic Drops Injection Other

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• • Route of Administration*

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• Additional Information

• Species