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Tb Screening Form

TB Screening Form

A TB screening form is a document used by medical professionals to screen for tuberculosis and determine when a patient is eligible for the TB vaccine.

Page 1

Patient Information

Email*

First Name*

Last Name*

Date of Birth*

Select date

Gender*

Phone Number*

Description:Screen for tuberculosis with ease using this TB screening form. This form is designed for medical professionals to determine a patient's eligibility for the TB vaccine. No coding required!

Efficiently screen for tuberculosis with this user-friendly TB screening form. Medical professionals can easily determine a patient's eligibility for the TB vaccine by filling out this form. The form is designed to be simple and straightforward, with no coding required. The form includes fields for personal information, medical history, and symptoms related to tuberculosis. By using this form, medical professionals can quickly and accurately assess a patient's risk of developing tuberculosis and take appropriate action. This TB screening form is an essential tool for any medical facility that wants to provide the best possible care to its patients.

Full Name*

Phone Number*

Address*

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Full Name*

Phone Number*

Address*

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First Name*

Last Name*

Date of Birth*

Select date

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What is your first name?*

What is your last name?*

What is your date of birth?*

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Full Name*

Address*

Phone Number*

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Introduction*

Consent*

I have read and understand the information provided.

I have had the opportunity to ask questions and have had them answered to my satisfaction.

I consent to participate in telehealth services.

Patient Name*

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First Name*

Last Name*

Date of Birth*

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What is your age?*

What is your gender?*

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Less than 3 months

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More than 1 year

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Full Name*

Date of Birth*

Phone Number*

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