Hi! What’s your name?

( Please type your full name)

And your date of birth?

(mm/dd/yyyy)

Which gender do you identify with the most?

Please tell us. What is the purpose of your visit today?

Got it! Have you ever been allergic to any of the following?

( select all that apply)

Almost done. Do you suffer from any of these medical conditions right now?

Have you ever suffered/ suffering from mental health issues?

Last thing! Are you under any medical care right now?

(We want to know if you are already taking any medications)