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. *This appointment form is for Clarity Testing Clinic only. All appointment requests made via this form are for Clarity Testing Clinic, located at 1950 Doctor's Park Drive, Suite B, Columbus, Indiana. Name* First Last Sex* Male Female Birth Date* 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?* Yes No Email* May we identify ourselves when contacting you to remind you of appointment?* Yes No Marital Status* Single Married Separated Divorced Why are you visiting Clarity Testing Clinic?* STI testing Pregnancy test Pap smear Are you a repeat client for STI testing?* Yes No If 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 period Date of last Pap Smear Due Date, if pregnant Do you have insurance?* Yes No Note: Please bring your insurance card if you have one. Cash and credit cards acceptedDo you know if you have been exposed to an STI?* Yes No If 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?* Yes No Please 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.PhoneThis field is for validation purposes and should be left unchanged.