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zip code

sex

What is your date of birth?

DO YOU HAVE THE FOLLOWING SYMPTOMS? CHECK ALL THAT APPLY

DO YOU HAVE THE FOLLOWING? CHECK ALL THAT APPLY

DO YOU HAVE ANY OTHER HEALTH CONDITIONS OR CONCERNS?

ANYTHING ELSE WE SHOULD KNOW?

ARE YOU CURRENTLY TAKING ANY MEDICATIONS? PLEASE INCLUDE OVER THE COUNTER MEDICATIONS AND HERBAL AND VITAMIN SUPPLEMENTS

DO YOU HAVE ANY ALLERGIES?

TREATMENT: ORAL ANTIBIOTIC

PLEASE ENTER YOUR PREFERRED PHARMACY INFORMATION HERE

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Total Payment Value: $25.00