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Get FL Confidential Report Of Sexually Transmitted Diseases Syphilis - Orange County 2023-2024

FLORIDA CONFIDENTIAL REPORT OF SEXUALLY TRANSMITTED DISEASES Protecting Your Health It s what we do Patient Name: DOB: SSN: Address: Phone: Email: Please print legibly OR use a label. RACE: WHITE BLACK OTHER AM INDIAN/ALASKAN ASIAN/PAC ISLANDER ETHNICITY: Hispanic / Non-Hispanic Provider Name:.

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