Order Consultation and Treatment

Fast, private and secure STD testing.

Personal Information

First Name

Last Name

Date of Birth (MM/DD/YYYY)

yyyy

Sex

Contact Information

Address

City

State

Zip Code

Can email treatment plan

Phone Number

Can leave phone message

Medical History

Race/Ethnicity

Drug Allergies

No known drug allergies.

Current Medications / Dosage

No medications

Requesting Treatment for: (select all that apply)

* Consultation does not include treatment for certain conditions.

Test Date (MM/DD/YYYY)

2024

Describe any symptoms you are currently experiencing

List any additional information the doctor may need to know

Partners

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

Choose a Pharmacy

5. Payment Information

Choose Payment Method

*Charges will appear as "RSC HEALTH"

Credit Card Number

Expiration

CVV

Zip Code

Order

Test	Price
name not given	$99.00
Total	$99.00