FT = Fast Track
CADH = Community ART Distribution – HCW Led
CADP = Community ART Distribution – Peer Led
FADG = Facility ART Distribution Group
Patient Phone No
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Indicate the patient’s telephone number
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Treatment Supporter Phone No
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Indicate the treatment supporter’s telephone number
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ARV regimen being distributed
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Enter the regimen, dosage and duration of the prescription in months in this space
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Other drugs/supplies being distributed and quantity
CPT / Dapsone:
Oral Contraceptives:
Condoms:
Other:
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If CPT/ Dapsone, Oral Contraceptives and any other drugs are provided, tick in the respective check box and enter the duration of the prescription in months in this space
Note: If provided with condoms enter yes after ticking the check box
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Name of pharmacist:
Signature:
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Enter the name and signature of the pharmacist (or HCW responsible for dispensing) in the spaces provided in the order first, middle and last name
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Name of ART distributor:
Signature:
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Enter the name and signature of the ART Distributor in the spaces provided in the order first, middle and last name
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