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ACMD New Referring Physician Information Form
Thank you for your interest in joining the ACMD Project.
The below form contains the MDS Disclaimer and Medication Availability Form for new referring doctors. Both sections must be completed prior to sending cases.
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Email
*
Your email
Name (First Name, Last Name)
*
Your answer
Hospital/Practice Name
*
Your answer
City and Country
*
Your answer
I give the ACMD Project permission to share my name and contact information with MDS so that MDS may contact me with membership opportunities.
*
Yes
No
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