Kitsap County Health District Adapted from WA DOH Form 347-102 2025

1. Click ‘Get Form’ to open it in our editor.
2. Begin by filling out the 'Patient Information' section. Enter the patient's last name, first name, middle name, and date of birth. Ensure accuracy as this information is crucial for identification.
3. Next, provide the patient's contact details including address, telephone number, and email. If the patient is unhoused or unstably housed in the past three months, check the appropriate box.
4. Indicate the patient's gender identity and whether they are currently pregnant. This information helps in understanding their health needs better.
5. Proceed to fill out the 'Diagnosis Date' and select applicable race categories and ethnicity. Check all that apply to ensure comprehensive data collection.
6. Complete sections regarding HIV status and diagnosis details. Be thorough in checking all relevant boxes for accurate reporting.
7. Finally, review all entered information for completeness before submitting your form through our platform.

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