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N. Gonorrhea Treatment Order Form

*Medications are to be used for N. Gonorrhea Treatment ONLY

  • Health Care Professional (HCP) Information

  • (Treatment Kits include; Ceftriaxone 0.25g vial, Lidocaine HCI 1% 0.9mL, Azithromycin 250mg tab x4)
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    Health Unit Use Only

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    Order filled by
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    YYYY slash MM slash DD
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