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Sign: 1 tablet ________ a day for ___ weeks Sign: 1 tablet ________ a day for ___ weeks
_______________________M. D _______________________M. D
License No. __________________ License No. __________________
S2. No: _____________________ S2. No: _____________________
Sign: 1 tablet ________ a day for ___ weeks Sign: 1 tablet ________ a day for ___ weeks
_______________________M. D _______________________M. D
License No. __________________ License No. __________________
S2. No: _____________________ S2. No: _____________________