Therapeutic Area

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Endometriosis

Uterine Fibroid

Date Of Birth (mm/dd/yyyy):
Invalid date of birth

Patient City:
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The patient attests that he or she is NOT receiving prescription drug coverage under any federal, state or government-funded insurance program. The patient further understands that if at any time he or she begins receiving prescription drug coverage under any federal, state or government-funded prescription insurance program, he or she will no longer be able to use the program.
Patient must agree to continue

Copay Program

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