Phone Number
-
Area Code
Phone Number
Name
First Name
Last Name
Date of birth
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-mail address
Drug allergies
Do you see a Primary Care Physician?
Please Select
-- Please Select --
Yes
No
If yes, please list name of physician.
When did the symptoms begin?
Symptoms
Painful Urination
Excessive Urine Production
Urinary Urgency
Other
Patient Eligibility:
Immunocompetent (have a normally responding immune system)
No Chronic Comorbities
No Known Urologic Abnormalities
No Known Urologic Abnormalities
Nonpregnant
Premenopausal
Patient Ineligible if any of the following characteristics are present:
History of childhood UTIs
Immunocompromised
Preadolescent or postmenopausal
Pregnant
Underlying metabolic disorder (e.g., diabetes mellitus)
Urologic abnomalities (e.g., stones, stents, indwelling catheters, neurogenic bladder, polycystic kidney disease)
Male gender
Today's Date
-
Month
-
Day
Year
Date
Enter name for consent:
*
Appointment
*Credit Card Payments Only* - Skip to Submit Form if Paying in Person
prev
next
( X )
UTI Test
$
35.00
Includes Screening and Testing Services. Antibiotic Therapy will be prescribed for positive UTI test results.
Total
$
0.00
Credit Card
Submit Form
For Office Use Only
Rows
Value
Temperature
Blood Pressure
Pulse
Respiratory Rate
Oxygen Saturation
For Office Use Only
Rows
Result
Leukocytes
Nitrite
Blood
For Office Use Only (UTI Treatment
Rows
Treatment
Nitrofurantoin macrocrystals 100mg 1 PO BID x5d
Trimethoprim-sulfamethoxazole 160mg-800mg 1 PO BID x3d
Ciprofloxacin 250mg 1 PO bid x3d
Phenazopyridine 200mg ! PO TID after meals as needed for dysuria #6 *Do not use for more than 2 days*
Should be Empty: