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Partner Notification/Referral Cards
Sample 2: Partner Referral Slip Used
in Zambian Antenatal Clinics for Women with Reactive Syphilis Serology
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Partner
Treatment Slip
|
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Index
number: _____
Name of facility:_____________
Address: _______________________
Please provide the bearer of this slip with the following treatment.
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Non-penicillin allergic
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Benzathine
penicillin G 2.4 MU IM
a) Single dose or
b) 1 dose a week for 3 weeks
Circle the treatment administered.
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Penicillin allergic
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a) Doxycycline
100 mg twice daily for 15 days or
b) Tetracycline 500 mg QID for 15 days
Circle the treatment
administered.
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Condoms provided
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• Yes
• How many _____270
• No
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Medical personnel
signature: ___________________________
Date: _______________ |
| Please return
this slip to the above address, or ask the bearer to return this slip
to the above facility through the post or his or her partner.
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Adapted from Control
of Sexually Transmitted Diseases: A Handbook for the Design and Management
of Programs. G. Dallabetta, M. Laga, and P. Lamptey, eds. AIDSCAP/Family
Health International, 1996.
© 2007 EngenderHealth
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