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Provide all information requested on the form. Specimens should be labeled with two (2) identifiers (e.g., patient name, date of birth, other unique patient ID). Should you need additional space, please submit a separate sheet of paper that includes patient name and date of birth. Specimen and STD-1 identifiers must match EXACTLY.
Use PDF (NEW!) for electronic AND hand-written completion. Word version contains instructions. (To request supplies of this form, please contact the Vaccine Preventable Diseases Program at 609-826-4861.)
Use PDF (NEW!) for electronic AND hand-written completion. Word version contains instructions. (Contact Child & Adolescent Health Program at 609-292-5666 for more information.) New fillable PDF form! Word document no longer available.
8 lip 2024 · The Sexually Transmitted Disease (STD) Program strives to prevent and reduce the effects of STDs in New Jersey through partner services, education, technical assistance, surveillance, and partnerships with local health and community organizations. STD Program Number: 609-826-4869
Forms for HIV, STD and TB Services AIDS Drug Distribution Program (ADDP)
The State of New Jersey Department of Health Sexually Transmitted Disease Program STD CASE REPORT FORM PO Box 363, Trenton NJ 08625-0363 | 609-826-4869 . PATIENT INFORMATION . LAST NAME FIRST NAME MIDDLE INITIAL DATE OF BIRTH ADDRESS CITY STATE ZIP CODE TELEPHONE (indicate home, work orcell) SEX AT BIRTH Male Female . CURRENT GENDER
We offer confidential STD screening, testing and education services at no cost to county residents. For more information call 609-265-5533. Burlington County Health Department 15 Pioneer Blvd., Westampton, NJ 08060. Masks are required. For patient safety and security, we require photo ID for all clinic clients.
