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Get and Sign Newcomer Health Program Supplemental Data Collection Form Vdh Virginia 2014-2022
Patient was referred for a chest x-ray was it WNL Was treatment recommended for Active TB Disease Pos Neg. Not Done LTBI Yes No Comments Person Completing Form Phone Print Name Last Name First Name Forms MUST be returned within 30 days of assessment in order for the LHD to receive reimbursement. Unknown Other Please provide an appropriate response to each question. Assessment Findings Is the patient Male Female Was the dental evaluation WNL Yes Was the hearing evaluation WNL Was the vision...
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