First Name
Last Name
Phone Number
Date of Birth
Email
Address
State Select State*AlabamaAlaskaArizonaCaliforniaFloridaTexasNew YorkIllinoisOther
Zip Code
City
Are you currently taking any medications?
YesNo
Select the infection you need medication for SelectA59.09 - TrichomonasB00.9 - HerpesA74.9 - ChlamydiaA54.9 - Gonorrhea
Are you allergic to any medications?
Are you pregnant or lactating?
Pharmacy Name
Pharmacy Phone Number
I certify that all answers are true and I agree to the company policies. I understand this is a self-pay service and insurance is not accepted.
Note: All medication is a self-pay purchase at CVS or Walgreens. Estimated costs:
Azithromycin: $20 - 30
Doxycycline: $30 - 60
Cefixime: $20 - 30
Acyclovir: $40 - 50
Metronidazole: $10 - 20
