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WebBotox (botulinum toxin type A) PHYSICIAN PATIENT INFORMATION INFORMATION ... opardize the customers life, health, or abiiy to regain maxmi um functon) Medication requested: ... Fax completed form to: (855) 8401678 -If this is an URGENT request, please call (800) 882-4462 WebForm 2.: TRUSTEE APPOINTMENT (NOT APPLICABLE IN QUEBEC) (Great-West Life Insurance for Personal, Group & Benefits in Canada) Form 1.: CERTIFICAT DU MDECIN TRAITANT MUTILATION ACCIDENTELLE (Great-West Life Insurance for Personal, Group & Benefits in Canada) This document contains both information and … Web3. Have your physician complete Part 3 of the Request for Information form; 4. Send the completed Request for Information form to us by mail or fax to the address or fax … importance of feet health