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Reporting Public Health Department for Providers County  Form

Reporting Public Health Department for Providers County Form

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Rectal Urethral Urine Vaginal Treatment Began mm/dd/yyyy Symptoms Untreated Will treat Unable to contact patient Patient refused treatment Referred to Partner s Treated Yes treated in this clinic Yes Meds/Prescription given to patient for their partner s Yes other No instructed patient to refer partner s for treatment No referred partner s to VIRAL HEPATITIS Diagnosis check all that apply Is patient symptomatic Hepatitis A Suspected Exposure Type s Hepatitis B acute Blood transfusion dental or...
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