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1 .Name of Parent/Guardian
2. Name of Patient
Address of Patient
3. Route through which medication is received
4. Name of facility through which the medication is received
5. Name of medication currently received
Formulation of medication currently received (if known)
Dosage of medication
How many times per day
Size/Volume of medication currently received
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and give I Am Billy permission to store and process all data on this form.
Data will be used by IAB to ascertain whether the patient is eligible for the receipt of gifted medication . Your data will not be shared with any third party (including the medical manufacturer) without the consent of parent/guardian.
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