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    HEALTHCARE PROVIDER CONTACT FORM

      Note: All fields marked in BOLD are required.

      NAME:

      FACILITY/PRACTICE:

      E-MAIL:

      PHONE:

      ADDRESS:

      CITY:

      STATE:

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      What is your medical discipline?:

      I currently perform testing in-house

      If no, which lab(s) do you send out to?:

      I currently order a Graves’ disease assay

      If so, which CPT code do you use?:

      How did you hear about us?:

      Please send me a Thyretain informational packet.
      Please contact me about a Thyretain educational webinar or to schedule a Thyretain educational presentation at my office.

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