STI Clinic Patient Booking Form

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Partner’s Gender *

Male

Female

Non-binary

Prefer not to say

Anatomic Sites of Exposure *

Oral

Vaginal

Anal

Prefer not to say

Any Suspected Infection, Infection Risk, or Symptoms in This Partner? *

Yes

No

Prefer not to say

Previous STIs *

Have you been diagnosed with any STIs before?

Yes

No

Prefer not to say

History of use of PEP (Post-Exposure Prophylaxis) *

Yes

No

Prefer not to say

History of use of PrEP (Pre-Exposure Prophylaxis): *

Yes

No

Prefer not to say

Risk of Blood-Borne Viruses (e.g., HIV, Hepatitis B/C) *

Yes

No

Prefer not to say

Vaccination History (Hepatitis B) *

Yes

No

Prefer not to say

Preferred Method of Receiving Results *

Phone

Email

In-Person

Other