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CDPH 8641 P (05/07)
California Department of Public Health
Office of AIDS
HIV/AIDS Surveillance Program
Physician’s Telephone Number
( )
CDPH 8641 P (05/07)
CDPH 8641 P (05/07)
MAIL COMPLETED FORM MARKED “CONFIDENTIAL” TO THE HIV/AIDS SURVEILLANCE PROGRAM
AT YOUR LOCAL HEALTH DEPARTMENT.
LHD contact information is available on the website: www.cdph.ca.gov/AIDS
CDPH 8641 P (05/07)
MAIL COMPLETED FORM MARKED “CONFIDENTIAL” TO THE HIV/AIDS SURVEILLANCE PROGRAM
AT YOUR LOCAL HEALTH DEPARTMENT.
LHD contact information is available on the website: www.cdph.ca.gov/AIDS