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¥ 1.0
Date: __________ I, ______________________________________, acknowledge and fully understand that I will be required to undergo antiviral prophylaxis for as long as it is medically prescribed.我被告知，我将对与这种药物相关的任何额外费用和其他必要的干预措施负责。符合：__________________________________
附件A：预授权清单和请求表格
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