|Classification / Identification:|
| ||Form Number:||014-4951-87E||Edition date: ||2021/07 |
| ||Title:||Respiratory Syncytial Virus (RSV) Prophylaxis for High-Risk Infants Program Synagis® Order Form for Single or Multiple Infants|
| ||Ministry:||Health|| || |
| ||Branch/ABC:||Drug Programs Delivery Branch|| || |
| ||Program:||Drug Programs Delivery Branch|| || |
| ||Purpose of Form:||To provide healthcare practitioners a standard form to order palivizumab for patients enrolled in the program.|| || |
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