Order Consultation and Treatment

Fast, private and secure STD testing.

1. Personal Information

First Name

Last Name

Date of Birth

yyyy

Sex

Male

Female

2. Contact Information

Address

City

State

Zip Code

Can email treatment plan

Phone Number

Can leave phone message

3. Medical History

Drug Allergies

No known drug allergies.

Current Medications / Dosage

No medications

Requesting Treatment for: (select all that apply)

Chlamydia

Gonorrhea

Herpes I

Herpes II

Trichomoniasis

* Consultation does not include treatment for certain conditions.

Test Date

2024

Describe your symptoms...

Any additional information...

4. Partners

Sexual partner(s) you wish to get treatment for:

4. Choose a Pharmacy

6. Acknowledge

Order

Test	Price
name not given	$99.00
Total	$99.00