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Microsoft word - orphan order form 2013 mar.doc

ORPHAN DRUG ORDER AND PAYMENT FORM TO BE FAXED OR MAILED
TO TRI-MED: - FAX No: (08) 9388 1744 : PHONE No:- (08) 9388 1444
Patient’s name: ----------------------------
Doctor: --------------------------------------------

Address: -----------------------------------

Address: -------------------------------------------
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Home Phone No: -------------------------
Surgery Phone No: ------------------------------
Work Phone No: --------------------------
Fax number -------------------------------
Mobile Phone No: -------------------------
Email contact --------------------------------
Name of Medication
Quantity
Required
DICYCLOMINE (100 x 20mg Tablets)
Colloidal Bismuth Subcitrate/ DENOL (1Box of 40 tablets/ 120mg each)
Colloidal Bismuth Subcitrate /DENOL (2Boxes of 40 tablets/ 120mg each)
FURAZOLIDONE (30 tablets bottle; 100 mg tablets)
FURAZOLIDONE (2 x 30 tablets bottle; 100 mg tablets)
NITAZOXANIDE (60 tablets a bottle; 500mg tablet)
NITAZOXANIDE (30 tablets a bottle; 500mg tablet)
NITAZOXANIDE (6 tablets a bottle; 500mg tablet)

NITAZOXANIDE Paediatric Oral Suspension 60 mls.
NITAZOXANIDE Paediatric Oral Suspension 30 mls.

TETRACYCLINE (60 Capsules/bottle; 250mg capsules)
TETRACYCLINE (2 Bottles as above for 14 day treatment)
RIFABUTIN (10 x 150mg tablets)
RIFAXIMIN (30 x 100mg tablets )
LEVOFLOXACIN (20 x 500mg tablets)
AUSTPOST EXPRESS- Please allow 4-5days)
OVER-NIGHT COURIER SERVICE
Please indicate where drugs are to be sent to [Cross-out one or the other in the columns on the right-hand-side of this row] Please note there is no GST charged if invoiced directly to the patient.
Drugs will be sent directly to patient unless otherwise directed by the Doctor.
Orders will be dispatched as soon as payment is received.

To supply drugs Tri-Med must have a copy of the TGA approval form faxed or posted to us prior to shipment of drugs. L(((
Cheques / Money orders, ----------OR-------- Visa Card or Master card Only
Address to which Money Orders &

If Paying by Master Card or Visa Card Only fill
Cheques should be made payable to
in the details below:
Tri-Med Distributors & posted to:
Name on Card: ---------------------------------------
Number on Card: -------------------------------------
Expiry Date: ---------- -Type of Card: -----------
Corporate Office:
11 Southport Street, West Leederville, 6007 Western Australia
Postal Address:
Locked Bag 15, Subiaco 6904 Western Australia
Telephone: +61 (0) 8 9388 1444
Facsimile: +61 (0) 8 9388 1744
E-mail: info@trimed.com.au
Web: www.trimed.com.au
ACN 080 507 277
ABN 79 010 030 857

Source: http://www.helicobacterpylori.net.au/uploads/1/7/5/3/17533181/orphan_order_form_2013_mar.pdf

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Microsoft word - ruzzier_cvs.doc

CURRICULUM VITAE ET STUDIORUM FABIO RUZZIER Nato a Trieste il 1° luglio 1949 1973 Laurea in Scienze Biologiche a pieni voti. 1974 (Apr-Dic) Borsa di studio presso l’Istituto di Anestesia Rianimazione dell’Università di Trieste. 1974 (Dic) Nomina a titolare di un assegno biennale di formazione scientifica e didattica presso la Facoltà di Scienze MM. FF. e NN. dell’Universi

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