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Get Reporting Sexually Transmitted Disease Form Florida

286 FAX: 407 665-3295 www.seminolecohealth.com Female Male Not Pregnant Pregnant Pregnancy due date CHLAMYDIA Opthalmia Oral/Pharyngeal Pelvic Inflammatory Disease (PID) Pneumonia Uncomplicated Patient Name: DOB: SS#: Address: Phone: Race: White Black Other AM Indian/Alaskan Asian/Pacific Islander Hispanic Non-Hispanic GONORRHEA Disseminated Gonococcal Opthalmia Oral/Pharyngeal Other resistan.

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