Appointments All information provided below will help us in scheduling your appointment. Please fill out the form below and we will then contact you to schedule your appointment at Clarity Testing Clinic. Name* First Last Sex*MaleFemaleBirth Date* Date Format: MM slash DD slash YYYY Age*After submitting this form, we will contact you to schedule your appointment. How would you prefer us to contact you?*Phone callEmailPhone*May we text you at that number?*YesNoEmail* May we identify ourselves when contacting you to remind you of appointment?*YesNoMarital Status*SingleMarriedSeparatedDivorcedWhy are you visiting Clarity Testing Clinic?*STI testingPregnancy testPap smearAre you a repeat client for STI testing?*YesNoIf you are a repeat customer, when were you here last?Has your name changed since your last visit? This Section for Women Only First day of last menstrual periodDate of last Pap SmearDue Date, if pregnant Do you have insurance?*YesNoNote: Please bring your insurance card if you have one. Cash and credit cards acceptedDo you know if you have been exposed to an STI?*YesNoIf yes, which STI?Note: If possible, please bring verification of your sex partner's positive STI test result.Have you had a new sexual partner in the last 3 months?*YesNoPlease describe any symptoms of a sexually transmitted infection that you are experiencing.*(bumps, discharge, odor, burning, pain) Additional Comments about your concernsInstructions: Please do not empty your bladder 1 hour prior to your appointment. Please come alone or have someone drop you off. We prefer to not have friends/family waiting in our reception area. Allow 1 ½ hours for your appointment.