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zip code

sex

What is your date of birth?

HAVE YOU HAD A YEAST INFECTION BEFORE?

DO YOU HAVE ANY OF THE FOLLOWING? PLEASE CHECK ALL THAT APPLY

PLEASE CHECK ANY THAT APPLY TO YOU

DO YOU HAVE OTHER MEDICAL HEALTH ISSUES?

LIST

ARE YOU ALLERGIC TO ANY MEDICATIONS?

WHICH ONES

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

WHICH ONES

TREATMENT

FLUCANAZOLE

payment details

Payment Information

Total Payment Value: $25.00