TDH Monkeypox Treatment Request Form

Thank you for initiating a request for tecovirimat treatment for your patient who has been diagnosed with monkeypox. Please fill out this form to the best of your ability and TDH will reach out to you regarding next steps.

Loading... Loading...
The option "" can only be selected by itself. Selecting this option will clear your previous selections for this checkbox field. Are you sure?
You have selected an option that triggers this survey to end right now.
To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.