Sexual Wellness Eligability Questionnaire

First Name

Last Name

Are you aged 18+ ?

Yes

Are you currently experiencing any symptoms (e.g. unusual discharge, pain or discomfort during intercourse or urination, sores, rashes, or itching in the genital area, bleeding during intercourse or urination)?

Are you currently experiencing any symptoms (e.g. unusual discharge, pain or discomfort during intercourse of urination, sores, rashes, or itching in the genital area, bleeding during intercourse or urination)?

Yes

Based on the informaton you have provided today, it is recommended that you schedule a visit with one of our physicians for a full review and examination.

Has your sexual partner recently tested positive for a sexually transmitted infection (STI) or experienced any symptoms?

Yes

For STI testing, patients under 18 must see a physician and be accompanied by a parent or legal guardian.

Continue

Based on the informaton you have provided today, it is recommended that you schedule a visit with one of our physicians for a full review and examination.

Would you like to book a Physician appointment?

Yes

No problem! If you change your mind and want to book a physician visit, you can easily do so by returning to this page.

Continue

I understand that during a nurse-led visit, if a physical examination or prescription is required, I will be referred to a physician for further evaluation, resulting in a separate physician visit charge.

I understand that if any test result is positive, I will need to have a consultation with a physician to discuss treatment and next steps, which will incur an additional charge.

Would you like to proceed with a nurse-led, understanding that this does NOT include prescriptions or physical exams?

Yes, Book Now

No, I would prefer to see a Physician