Facilities Form

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Facilities Form

Facilities Form

Please provide information concerning the need for physicians orders, information to be included in physicians orders, if there is a fee required, if insurance is accepted, etc.
Please list the address where therapeutic phlebotomies can be obtained.
I do hereby consent and authorize the Hemochromatosis Information Society (HIS) and its affiliates to publish the information uploaded by me through this form on the HIS website. The information provided may be used in perpetuity and published, in whole or in part, in any and all media.