Name

Email Address

Age

Birth Date

Sex Sex Male Female

Phone

May we text you at this number? May we text you at this number?YesNo

After submitting this form, we will contact you to schedule your appointment. How would you prefer us to contact you? After submitting this form, we will contact you to schedule your appointment. How would you prefer us to contact you? Phone call Email

May we identify ourselves when contacting you to remind you of your appointment? May we identify ourselves when contacting you to remind you of your appointment?YesNo

Marial Status Marial Status Single Married Separated Divorced

Why are you visiting Clarity Testing Clinic? Why are you visiting Clarity Testing Clinic?STI testingPap smearPregnancy test

Are you a repeat client for STI testing? Are you a repeat client for STI testing? Yes No

If you are a repeat customer, when was your last visit?

Do you have insurance? Do you have insurance? Yes No Note: Please bring your insurance card if you have one. Cash and card are also accepted.

Do you know if you have been exposed to an STI? Do you know if you have been exposed to an STI? Yes No

If yes, which STI?

Have you had a new sexual partner within the last 3 months? Have you had a new sexual partner within the last 3 months? Yes No

Date of last menstrual period

Date of last Pap Smear

Due Date, if pregnant

Please describe any possible symptoms of a sexually transmitted infection that you are experiencing: (bumps, discharge, odor, burning, pain, etc.) (bumps, discharge, odor, burning, pain, etc.)

Additional comments about your concerns: