Patient Syphilis Record Search Request Form

This form is used to confirm previous patient syphilis serology and treatment history from state, county or local public health authorities. You must call the Illinois Perinatal Syphilis Warmline at 1-800-439-4079 for pre-approval and guidance before submitting this form. Once pre-approved, this form and a coversheet that includes your facility or institution’s letterhead should be sent to the Illinois Perinatal Syphilis Warmline via confidential fax# 312-694-0843.