Snohomish County TPOXX IND Enrollment and Treatment Request Form

Thank you for your interest in providing TPOXX. This form is for healthcare providers in Snohomish County. If you are not a healthcare provider and/or if you are not located in Snohomish County, please do not complete this form. If you are a healthcare provider in another county, please contact your local health jurisdiction.

For Snohomish County healthcare providers, please fill out this form to the best of your ability and we will reach out to you regarding next steps.

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* 1. What is the purpose of your request?

Request information about becoming a TPOXX EA-IND provider

Request TPOXX RX form

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* 2. Facility name

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* 3. Facility location/department

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* 4. Facility type

Emergency Department

Hospital

Sexual health clinic

Other outpatient/clinical office

Urgent care

Pediatric

OB-GYN

Other (please specify)

Snohomish County TPOXX IND Enrollment and Treatment Request Form

Question Title

* 1. What is the purpose of your request?

Question Title

* 2. Facility name

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* 3. Facility location/department

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* 4. Facility type

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* 5. Investigator name

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* 6. Investigator phone number

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* 7. Investigator email