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Ellura UTI Management
Māge Probiotic for Her
Via Vaginal Moisturizer
Scientific Studies
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For Patients
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Patient Referral Form
Patient Referral Form
Healthcare Provider
Provider Name
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Mr.
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Enter Provider First, Last Name
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Office/Practice Name (if applicable)
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Patient Information
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Recommended Supply
Select Recommended Supply
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Ellura 30-DAY SUPPLY
Ellura 60-DAY SUPPLY
Ellura 90-DAY SUPPLY
Ellura ONGOING USE – we will discuss with patient based on automatic refill program costs
Māge probiotic 30-DAY SUPPLY
Māge probiotic 90-DAY SUPPLY
Via vaginal moisturizer
Please recommend patient supply.
