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Provider Interest Form: Syphilis Testing & Treatment Locator

ATTENTION: The Syphilis Testing & Treatment Locator information has now been incorporated into the STI/HIV Testing & Treatment Locator Dashboard! If you're interested in having your clinic included in this Locator, click here to take the Provider Inventory Survey.

If you'd like to only be included in the Syphilis Testing & Treatment Locator, continue to fill out this google form. Please check the current version of the dashboard here to make sure your organization is not already included before filling out this form.

Any questions can be directed to Sarah (sarah.sohlberg@state.co.us). 

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Your name (First & Last) *
Your email address
Name of your organization *
Address (if your organization has multiple office locations, please fill out a form for each location) *
County *
Website URL
Organization Phone Number *
Days/Hours of Operation
Please check off which of these syphilis testing services are provided at your organization? (Check all that apply) *
Required
Please check off which of these syphilis treatment services are provided at your organization? (Check all that apply) *
Required
Is your organization covered by HRSA's 340B Drug Pricing Program? *
More info on HRSA's 340B Drug Pricing Program:
https://www.hrsa.gov/opa
Typical Syphilis Treatment Appointment Availability *
Insurance accepted at your organization:
Can we list your organization's name and contact info as a testing and/or treatment provider on the Syphilis Testing & Treatment Locator Dashboard? *
How to schedule/make an appointment:
Please briefly describe your scheduling guidelines, including specific populations served, whether patients need to be established within the clinic, etc. 
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