UNION PHARMACY

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Name (if different than patient name, i.e. parent or guardian)

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Pharmacy Name

Pharmacy Fax #

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Select your Telemedicine Kit
COVID-19FluStrepUTIAnemiaBirth ControlErectile Dysfunction

Symptoms Patient is Experiencing
COVID-19/Coronavirus symptomsSore throatFlu-like symptomsFatigueDiscomfort when urinatingErectile Dysfunction symptomsOther/none of the above

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