Med Section In-Person STI Screen Interest Form

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Please complete this form if you would like to receive an STI test. At this time, we are offering in person appointments for folks that either need a routine, asymptomatic testing or are symptomatic for an STI and require an appointment. All of this information is private and confidential and will not be shared outside of the BFC. The information you provide below will not in any way affect the quality of your appointment.

Due to our scope of training, our volunteers can only see a limited range of appointment types. Please be as descriptive as possible in the form if you're symptomatic and we will do our best to either see you for an appointment or refer you to a more appropriate clinic or BFC section.

Once you fill out this appointment form, we will contact you as soon as possible to schedule you for an appointment. At this time, we generally have availability for appointments on Fridays at 7:00 PM. If we're all booked for the week, we will let you know and refer you to another clinic or BFC section pending your need.

We test for gonorrhea, chlamydia, HIV and syphilis. Unfortunately, we are unable to test for herpes or monkeypox. For folks with external genitalia, we conduct optional physical exams. Appointments last for approximately 1.5 hours. If you have any questions about our services, please email medsection.coords@berkeleyfreeclinic.org.

What's your first and last name? *

Your pronouns

he/him/his

she/her/hers

they/them/theirs

Other:

Clear selection

Your date of birth *

YYYY

Your email

Phone number *

Any alternative forms of contact that we should know of?

Can we leave a voicemail at this number?

Yes

Other:

Clear selection

Can we text this number?

Yes

Other:

Clear selection

What type of genitalia do you have? This question is solely to understand if our volunteers are able to see you for an appointment based on our scope of training.

Internal genitalia (vagina)

External genitalia (penis)

Other:

Clear selection

Which of the below options best describe your current needs/concerns? Please click as many options as you’d like: *

I have no symptoms of an STI and am interested in a routine STI screen

I have a partner who has been diagnosed with an STI

Pain on urination

Peeing more often than usual

Unusual discharge from the internal genitalia

Unusual discharge from the external genitalia

Deep pelvic pain

Pain during sex

Unusual cramping

Unusual spotting between periods

Other:

Required

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