Free ANTIVIRAL TREATMENT REPORTING - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Public Health F-00064 (05/09)

STATE OF WISCONSIN Bureau of Communicable Diseases

ANTIVIRAL TREATMENT REPORTING
Please complete and fax the form to (608) 267-2832. (Items in bold are required fields). For questions about the form please contact (608) 266-9691.

Patient Information Name (Last, First MI): _________________________________________________________ Date of Birth: ______/______/_______ Street Address: _______________________________________________________________ City: ____________________________________________ State (if not Wisconsin): ___________________________________ Zip: _________________ Phone: ( ______ ) _________ - ______________________

Provider Information Hospital/ Clinic Name: _________________________________________________________ Ordering Authority: ___________________________________________________________ Administering Clinician/Pharmacist: _____________________________________________

Treatment Information: Date Administered: ______/______/_______ Product (including dosage): ____________________________________________________ NDC/Mfr Item Number: ________________________________________________________ Lot number: ________________________________________________ Expiration Date: ______/______/_______