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| {{{field|dose5|input type=Number|size=5}}}
| mg/day
|-
| colspan="4"|-| colspan="2" | '''Conversion drug'''| colspan="2" | {{{field|replacement|mandatory|values=diazepam,oxazepam,clonazepam,chlordiazepoxide|default=diazepam }}}
|}
{{{end template}}}
