Herpes Blood Test Request Form
Please complete this form to request a herpes blood test. Your information will be kept confidential and used only for medical purposes.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Non-binary
Prefer not to say
Other
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Appointment Date and Time
*
Reason for Requesting Herpes Blood Test
*
Experiencing symptoms
Routine screening
Partner recommendation
Doctor's advice
Other
Are you currently experiencing any of the following symptoms? (Select all that apply)
*
Sores or blisters
Itching or burning sensation
Pain during urination
Flu-like symptoms
No symptoms
Other
Have you ever been diagnosed with herpes or any other sexually transmitted infection (STI)?
*
Yes, herpes
Yes, other STI
No
Prefer not to say
Please list any medications you are currently taking (optional)
Do you have any allergies to medications or latex?
*
No known allergies
Yes (please specify below)
If yes, please specify your allergies
Signature (Please sign below to authorize your request)
*
Submit Request
Submit Request
Should be Empty: