STI Treatment Form



Submit STI Treatment Information for integration into the CDPHE PRISM System


Colorado Department of Health DCEED-STI-Registry A3
303-692-2697
4300 Cherry Creek Dr. South Denver, CO 80246-1530



Provider Information

Search for the provider you are entering. If not listed, click NEW to add.





Physician Information

First Name
Last Name


Reporter Information

First Name
Last Name
Phone Number


Patient Information

First Name
Middle Name
Last Name

Race
Hispanic
Date of Birth
(mm/dd/yyyy)

PatientID/MR#
Self Reported Gender
Sex At Birth

Address
Email Address

State
City
County
Zipcode

Phone Number
Pregnancy
PID

Treatment Summary Information

CDC Treatment Guidelines


Testing Comments


OPTIONAL: To receive an email confirmation, enter your email address:

Save Provider and Reporter Information for next submission?