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Infusion Therapy Venous Access Referral Form
Orders are fulfilled per Community Protocols documented on page 2, unless physician requests otherwise. We process only completed referrals (signed, dated and legible). Confidential when completed. Fax completed form to 613.745.6984 or 1.855.450.8569. If you received this form in error, please call 1.800.538.0520.
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