Mpox Intake Form

Full Name

First NameLast Name

Date of Birth

Date

Email Address

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Emergency Contact Name

First NameLast Name

Emergency Contact Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Have you traveled internationally in the last 30 days?

If yes, note that down.

Have you had any close contact with someone diagnosed with Mpox?

If yes, explain.

Do you have any current symptoms? (Please check all that apply)

Please list any medications you are currently taking

Do you have any known allergies?

Have you been vaccinated for Mpox?

If yes, when was your last vaccination?

Date

Additional Comments or Concerns