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

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Reporting Blood Lead Results Electronically Sign-up Form