Testing today: Medications/Supplies: Referrals made: N/A N/A MV / Folic Acid GC # of bottles given____________ 1-800-QUIT-NOW    Chlamydia issued (#) _____________ Cooper Clayton Classes   Foam VDRL  issued (#) ___________ PCP  Condoms HIV  ECP MNT   Urine PT / UCG:  Pos Neg FP Medical Revisit Control Method given:________________________________  Birth Other:  Other: ________________________________________________________  and Condoms offered, pt declined Foam Other:  Notes: Healthcare Provider Signature: Date: Recommended RTC:
Testing today: N/A  GC  Chlamydia  VDRL  HIV  Urine PT / UCG: Pos Neg Other:  Medications/Supplies:  MV / Folic Acid # of bottles given____________ Foam issued (#) _____________ Condoms issued (#) ___________  ECP Birth Control Method given:________________________________ ________________________________________________________ Foam and Condoms offered, pt declined  Other: Referrals made: N/A  1-800-QUIT-NOW  Cooper Clayton Classes  PCP  MNT  FP Medical Revisit  Other: Notes: Healthcare Provider Signature: Date: Recommended RTC:
BC1ResupplyForm112.docx