Patient Information

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(if different than legal name):
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(number and street):*
 
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(if unknown enter 99999):*
     ext:
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*** For reports of positive chlamydia, gonorrhea and syphilis cases only ***

   
   Disease: *    Chlamydia    Chlamydial Ophthalmia Neonatorum  
Pelvic inflammatory Disease
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    Please check if patient was also positive for Gonorrhea

   Disease: *    Gonorrhea    Gonorrheal Ophthalmia Neonatorum    Gonorrhea - Resistant  
Pelvic inflammatory Disease
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  SYPHILIS: Please report all positive test results and negative reflex test results.
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Neurologic symptoms?
Ocular symptoms?
Otic symptoms?
 
Positive
Negative
Positive
Negative
Positive
Negative
Positive
Negative
Positive
Negative
Positive
Negative
  
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