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NEPHRO-TECH, INC.

P.O. Box 16106

Shawnee, KS 66203

fax 785-883-4109

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*Licensed Practitioner's Name:    Co. Name: 

    *Street Address:  

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    *Phone Number: Fax Number:

*Place an X by the products you would like:

Nephron FA^® Nephplex^® RxVital-D Rx™ MagneBind^® 300 MagneBind^® 400 Rx

    *Licensed Practitioner's Signature: *State Lic. #:

complete the information below if samples are to be sent to a dialysis unit

    Co. Name:     *Contact Name: 

    *Street Address:

    *City: *State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware D.C. Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming *Zip Code:

    *Phone Number: Fax:

    Number of patients:          Hemo:          PD:

FOR NEPHRO-TECH, INC. USE ONLY - DO NOT WRITE BELOW

Date Request Received: Date Samples Shipped: Auth. By:  Form #:

FA NP D₃ M3 M4