Get the free PLEASE NOTE: Use this form for reporting all conditions except Tuberculosis and cond...

Laboratory Name SEXUALLY TRANSMITTED DISEASES STDs Gender of Sex Partners check all that apply STD TREATMENT If reporting Syphilis Stage Primary lesion present Secondary Early latent 1 year Latent unknown duration Late latent 1 year Late tertiary Congenital Neurosyphilis Treated in office Given prescription Drug s Dosage Route RPR Pos Titer Neg VDRL FTA-ABS Neg TP-PA EIA/CLIA CSF-VDRL Syphilis Test Results Treatment Began mm/dd/yyyy Untreated Will treat Unable to contact patient Patient...

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