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SIGNATURE: This form may be signed only by a medical doctor, including a psychiatrist, a doctor of osteopathy, or by a physician’s assistant or nurse practitioner working in the practice of a medical doctor or doctor of osteopathy. Signature

Date form was completed:

(Physician or Nurse Practitioner or, Physician’s Assistant)

032-03-1040-11-eng (10/22)

or Name ( Please print) Office telephone number: Office Address OFFICE STAMP