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Get AK Confidential Sexually Transmitted Disease (STD)/HIV Report Form 2016-2023

Disease Report Form to report other infectious diseases. Forms may be found at http://dhss.alaska.gov/dph/Epi/Pages/pubs/conditions/crforms.aspx. Patient Information Last Name _____________________________________ First Name______________________________ MI _______ Date of birth ____/____/______ (mm/dd/yyyy) Race: Sex: Female Pregnant: No Yes; # of weeks ________ Unknown Male Gender of Sex Partners: Male Female Unknown Transgender (check all that apply) White Black Alaska Native/American In.

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