Reporting Blood Lead Results Electronically Sign-up Form

Please complete this form below to sign-up to report blood lead reports electronically. Once you submit your information a person from the Texas Department of State Health Services will contact you. They will provide instructions on how to upload the blood lead reports to a secure ftp server.

All the fields below are required.

Clinic Name

Organization

Tax ID

Healthcare Provider Name

Contact Person

Supervisor Email

Phone

Supervisor Phone

Fax

Street Address

City

State

ZIP

CAPTCHA

Math question

5 + 2 =

Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.

This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.

Menu Title

Menu Title

Menu Title

Menu Title

Menu Title

Reporting Blood Lead Results Electronically Sign-up Form