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Get RI Sexually Transmitted Disease Confidential Case Report Form 2011-2024

RI 02908 PHONE: (401) 222-2577 FAX: (401) 222-1105 1. Mail or fax fully completed report within 4 days of diagnosis or as soon as treatment is prescribed. 2. FAX or Phone partial report immediately if partner services are requested (see V. below) or syphilis reporting criteria are met. I. PATIENT INFORMATION: II. FACILITY INFORMATION: Last Name First (full) Name MI Street Physician or Facility Name Apt. # City/Town Zip Code Sex Male Female Transgender: M to F F to M Ethnic Origin His.

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