Patient Information

Patient ID:
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First:
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Address:
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Zip:
Phone:

Sex: Male Female
Race: (check all that apply)
White Black or African American
American Indian/Native Alaskan Asian
Native Hawaiian/Pacific Islander Other
Ethnicity: Non-Hispanic Hispanic Unknown

Submitter Information

Clinician/Practitioner:

Clinician/Practitioner: Last:
Clinician/Practitioner: First:
Clinician/Practitioner: Middle:
Practitioner NPI:
Hospital/Lab/Clinic Name:
Address:
City:
State: Oklahoma Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip:
Program: Family Planning STD Child Health Chronic Disease Maternity Dysplasia Tuberculosis Communicable Disease Adolescent Health Adult Services
Phone:
Fax:

Clinical Information

Clinical Onset:
Antibiotics:
Clinical Diagnosis: