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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
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
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Month
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Day
Year
Date
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UTI Test
$
35.00
Includes Screening and Testing Services. Antibiotic Therapy will be prescribed for positive UTI test results.
Total
$
0.00
Credit Card
Appointment
For Office Use Only
Value
Temperature
Blood Pressure
Pulse
Respiratory Rate
Oxygen Saturation
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