EPT (retail) STI Medication Dispensed Reporting
Complete separate form for each patient CDU EPT (retail) STI medication was provided for.

If the name of the facility does not appear below please email cdusupplies@wyo.gov.
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Email *
Location: If your location does not appear in this list email cdusupplies@wyo.gov  *
EPT (retail) medication provided #1 *
Medication #1 lot number *
Medication #1 expiration date - If month and year only, use last day of that month for day. *
MM
/
DD
/
YYYY
Medication #1 NDC number *
EPT (retail) medication provided #2
Medication #2 lot number
Medication #2 expiration date - If month and year only, use last day of that month for day.
MM
/
DD
/
YYYY
Medication #2 NDC number
Diagnosis (check all that apply) *
Required
Your Name *
Your contact phone number *
Comments
A copy of your responses will be emailed to the address you provided.
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