Date of Birth(Required)

Sex(Required)

Male

Female

Other

Are you pregnant(Required)

Yes

No

Are you breastfeeding(Required)

Yes

No

Phone(Required)

Email

EIRCODE (or Postal Code)

Name(Required)

First Last

Address(Required)

Apt / House Number/ House Name Remainder of Address

You MUST arrive 5 minutes BEFORE your appointment, If you are late the Doctor will NOT meet you. Do you accept this(Required)

Yes

No

Main Reason for Medical Consultation (Choose Only One)(Required)

Describe the Other Reason(Required)

Which Ear(Required)

Left

Right

Which one of the following best describes your sexual relationships(Required)

Exclusively with WOMEN

Exclusively with MEN

With both WOMEN and MEN

Do you take PrEP medication(Required)

Yes

No

What is your HIV Status(Required)

List the medication, Milligram & Number (Dosage) Required

Preferred Pharmacy(Required)

If we need to issue a prescription for medication, please name your preferred pharmacy and address

Total

Credit Card

Card Details

Cardholder Name

Patient Questionnaire

PQS