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* Default contact # is home. Click to choose alternate contact phone #

▲ ▼ (Duration of symptoms is days) Drug Interaction Checker ▲ ▼
Meds:
Recent eGFR: Date:
Stamp Signature
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Subject:
Choose Tickler reminder date 4 weeks 8 weeks
Creative Commons License Paxlovid Rx eFORM, updated V4_Jul8_2022 by Dr. John Yap, is licensed under a GPL.
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