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Medications
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Labs
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Contact Now
Sexual
Health
Sexual Consultation Form
Full Name
*
.
Date of Birth
*
Please enter your date of birth
Gender
*
Male
Female
Please select your gender
Phone Number
*
Please enter your phone number
Are you under the age of 18 ?
*
Yes
No
Email Address
*
Please enter your email address
Email Address
*
Please reenter your email to confirm its correct
Street Address
*
City
*
State
*
ZIP Code
*
Do you have a fever
*
Yes
No
Do you have any medical conditions?
*
Yes
No
If yes, please list your medical condition
Please enter your medical condition
Do you have any allergies?
*
Yes
No
If yes, please list your allergies
Are you taking any medicines, supplements, herbal remedies, or other prescriptions
*
Yes
No
If yes, please list your medications
Do you have chronic liver, Heart or Kidney problems?
*
Yes
No
If yes, please list your problem
Are you Pregnant or breastfeeding?
*
Yes
No
If yes, please list your problem
Reside in the state of Michigan?
*
Yes
No
If yes, please list your problem
Are you on Medicare or Medicaid?
*
Yes
No
If yes, please list Medicare or Medicaid
Reason for treatment (Please select all that apply)
*
You or your partner test positive for chlamydia
Was exposed to someone that has or possibly has chlamydia
Having symptoms of Chlamydia
Had unprotected sex and would like to be protected
Please describe the outbreak?
*
Vaginal or penile discharge
None
Other
Other
Do you have any of these symptoms? (Please check all that apply)
*
White or Yellow vaginal/penile discharge
Burning or frequent urination
Vaginal or penile irritation or itching
Women - Vaginal bleeding between periods
Men - Painful or swollen testicles
Lower abdomen or pelvic pain
Back (flank) pain
Other
other
We recommend that you get a lab test after treatment to confirm the infection is completely treated for $39.99
*
Yes - Self
Yes - Self + Partner
No - I'll get my own test after treatment
We recommend that your partner get treated to avoid reinfection get them treated for 50% off
*
Yes
No
We have partnered with numerous testing facilities to offer lab tests service at a lab close to you nationwide. You can now order lab tests from the comfort of home. Instruction on where to obtain test will be provided after order is placed.
We appreciate our patient's contribution to their own care. Select your drug of choice, if any, from our treatment options below
*
Azithromycin & Doxycycline (CDC recommendation) - $10 extra
Azithromycin
Levofloxacin
Doxycycline
Add prescription diflucan for yeast infection - $10
*
select
Yes - $10.00
No - $0.00
Terms of Use and Privacy Policy
*
I consent to treatment by the healthcare provider named above for the medical conditions indicated. I acknowledge that I have provided complete and accurate information to the best of my knowledge.
See the following links for Terms of Use and Privacy Policy
Pharmacy name
*
Pharmacy Phone Number
Pharmacy Address
*
Billing Name
*
.
Billing Address
*
Credit / Debit Card
*
Submit
ANSWER HEALTH QUESTIONS
Tell us about your health, medical history and symptoms.
TREATMENT
Your personalized treatment plan will be sent to the pharmacy of your choice within a couple of hours.
PICK UP
Pick up your medication at your pharmacy or lab. Yes its that simple !
Previous slide
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TREATMENT
Your personalized treatment plan will be sent to the pharmacy of your choice within a couple of hours.
PICK UP
Pick up your medication at your pharmacy or lab. Yes its that simple !
ANSWER HEALTH QUESTIONS
Tell us about your health, medical history and symptoms.
Previous slide
Next slide
ANSWER HEALTH QUESTIONS
Tell us about your health, medical history and symptoms.
TREATMENT
Your personalized treatment plan will be sent to the pharmacy of your choice within a couple of hours.
PICK UP
Pick up your medication at your pharmacy or lab. Yes its that simple !
Previous slide
Next slide
