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Today's Date
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First Name
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Last Name
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Email Address:
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Phone Number:
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Let's Get Tested - Select Your Test:
Couples STD Testing
HIV - Treatment - Become Undetectable & Stay Health
Prep - 1 pill a day for HIV Prevention
PeP - Emergency 48 hour exposure Treatment
STD - Testing and Treatment
Birth Control - Starting or Continuing Regiment
Male Enhancement Consultation
Other
How did you hear about us?
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BING
YELP
GOOGLE AD
GOOGLE SEARCH
Y-100 RADIO
103.5 THE BEAT RADIO
WMBM -1490 AM
Insurance Status
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Yes - I have Insurance
No - I need an Assistance Program
Can you come into the office to test and meet with the DOCTOR in the morning at 8am (NO SUNDAYS)?
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YES - I will be there in the morning 8am (TEXT the word CLINIC to 72345 for Address)
NO - Please provide me with another time
What time can you come in today or tomorrow? -Our staff goes to lunch from 12 Noon to 1:00 PM. Last Appointment at 4:00 (SATURDAYS 9AM - 2PM) (NO SUNDAYS). *
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Time for Appointment
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8 AM
9 AM
10 AM
11 AM
1 PM
2 PM
3 PM
4 PM
Appointment Status
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I'M BOOKED - SEE YOU SOON
PLEASE CALL ME
www.aliveandwellprogram.com