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Get WA DOH 347-102 - Thurston County 2016-2024

Rt STDs within three work days (WAC 246-101-101/301) PATIENT INFORMATION LAST NAME FIRST NAME ADDRESS CITY DAY YR ( ETHNICITY No DAY RACE (Check all that apply) GENDER OF SEX PARTNERS White Asian Black Other Unknown American Indian/Alaskan Native Native Hawaiian/Other Pacific Islander Male Female Both Unknown HIV TESTED AT THIS VISIT?* Symptomatic Routine Exam – No Symptoms Exposed to Infection Unknown DATE OF DIAGNOSIS MO ) REASON FOR EXAM (Check one) If Female, PREGNANT? .

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