Please send me the following item:
5 patient-initiation doses of Arava® (leflunomide) [each containing 3 X 100-mg tablets]
 
 
(Please check one)
MD
DO
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Practitioner's Name:  
 
Street Address:  
 
City:       State:         Zip: 
 
Phone Number:        Date of Request: 
        (Enter 10 digit no.)
 
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State License Number:
  (Required for initiation dose requests)
 
Signature (required) :
  (Actual signature required, no stamps please)
 
 
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Last Update: October 2008