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CLIFFORD W. BASSETT, M.D.
Allergy & Asthma Care of New York
635 Madison Avenue
3rd Floor
New York, NY 10022
Tel: 212-759-8644		 381 Park Avenue
South Suite 1020
NY, NY 10016
212-260-6078
 150 Broadway
Suite 1601
NY, NY 10038
212-964-1295		 77 Mercer St
NY, NY 10012
212-274-0800		 142 Joralemon St.
Suite 3A
Bklyn Heights, NY 11201
718-246-3700
Pharmacy Info Email Electronic Prescription Program



Patient's Name:        _________________________________________
 		Date of Birth:______________     Age: _______



Pharmacy Name:      __________________________________________________________________



Pharmacy Address: __________________________________________________________________

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Pharmacy Phone:     __________________________________________________________________