Get the free gonorrhea case investigation record form - cdph ca

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If you have received this facsimile in error please immediately notify us at the telephone number listed above. CDPH 9064 11/14 CGSS 2. 0 - 11/17/2014 Page 1/5 PATIENT INTERVIEW FORM Process Information Patient Name Interviewer Name Contact Attempt Outcome check one only for each attempt Answer/Interviewed 1 date No Answer/No Message Answer/Hang up Answer/Reschedule DIS call back Answer/Refusal Number out of...
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