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Click ‘Get Form’ to open it in the editor.
Begin by filling out the Patient Information section. Enter the patient's first name, last name, and IDOC number if applicable. Indicate whether expedited partner therapy was given for chlamydia or gonorrhea.
Complete the address fields including street address, apartment number, city, zip code, county of residence, and state. Ensure all information is accurate for effective communication.
Select the appropriate race and ethnicity options from the provided checkboxes. This information is crucial for demographic tracking.
Fill in the date of birth and current gender fields. Specify if the patient is pregnant and provide an estimated due date if applicable.
In the Diagnosis section, check all relevant STIs diagnosed. Include laboratory test dates and results as necessary.
Finally, complete the Treatment (RX) Information section by entering relevant RX codes based on treatment administered. Ensure to include facility details where treatment occurred.

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Versions	Form popularity	Fillable & printable
2022	4.8 Satisfied (22 Votes)
2018	4.1 Satisfied (37 Votes)
2016	4.4 Satisfied (39 Votes)

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