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Get Ia Treatment Of Latent Tuberculosis Infection (ltbi) Medication Request Form 2020-2024

Sease by phone: Nurse Consultant 515-281-8636 or Program Manager 515-281-7504 Demographics Name: (Last, First) Date of Birth: (MM/DD/YYYY) Weight: Street Address: City: Zip: County of Residence: Gender: Phone: Medication Allergies: Male Pregnant: Female Yes No Interpreter Required (specify language): Diagnostics Tuberculin Skin Test Date: Results in mm: IGRA (Blood) Test Date: Results: Positive Negative Results: Normal Abnormal (Do not include erythema) Chest X-ray Dat.

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