Syphilis Treatment Referral Form

Referral Date

Patient Information

First name*

Name field is invalid or blank

Last name*

Name field is invalid or blank

Date of birth*

Date field is invalid or blank

Sex at birth*

Male

Female

Gender

Street address *

Address name field cannot be blank

City *

City field cannot be blank

State *

State name field cannot be blank

Zip code *

Zip code is blank or invalid.

Phone number*

Format should be 217-123-4567

Alternate phone number

Format should be 217-123-4567

Allergies, enter none if no known allergies.*

Allergy field is invalid or blank

Signs / Symptoms, at time of exam

If NEUROLOGIC/OCULAR/OTIC involvement is suspected refer to specialized care for evaluation of symptoms. C-UPHD only provides IM and oral treatment.

Diagnosis

Stage (select 1):*

Primary

Secondary

Early Latent (NPNS)

Late Latent or Unknown

Unknown

Attach a file

You may attach a PDF or JPG, or PNG file with a maximum size of 10MB.

No file selected

Referred By

Referring Provider*

Provider field is invalid or blank

Medical Institution*

Medical Institution field is invalid or blank

Provider Phone*

Provider phone is invalid or blank

Provider Fax*

Provider fax is invalid or blank

Name of person completing the form*

Provider Signature field is invalid or blank

Date*

Date field is invalid or blank

The Champaign-Urbana Public Health District is requesting disclosure of information that is necessary to accomplish the statutory purpose as outlined under Illinois Sexually Transmissible Disease Control Act (410 ILCS 325, ch. 111 1/2, par. 7401 et seq). Disclosure of this information is MANDATORY.

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