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 For example:
Medicine name: Duloxetine
Dose: strength of the medicine dispensed and total daily dose (20mg capsules, 2 daily)
Pharmacy: Full address including zip code, please do not fill out the phone numbers.
Name on prescription: child name or adult patient name

Please make sure you have shopped pharmacies for the best price, for example looked up GoodRX app for manufacturer coupons and are sure about where you need the refill sent. 

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