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Male Female Other

    1 - What symptoms are you experiencing today? *

  • Pain or burning when urinating
    Frequent urge to urinate
    Sudden urge to urinate
    Blood in the urine
    Other

    • 2 - Was your past treatment effective?


    • Please also list how long you used them (or if you are still using them). If you haven't tried any treatments, you can leave this question blank.

    3 - Have you been diagnosed with urinary tract infections in the past?*

  • Yes
    No

    • 4 - How many urinary tract infections do you have per year?*

  • 0-3 UTIs per year
    4+ UTIs per year

    • 5 - Do you take any medicines, vitamins, or supplements?


    • Please list them here.

    6 - Please list any allergies you have.


    • Include any allergies to food, dyes, medications (including prescription medications and over-the-counter medications), insect venom, herbs, vitamins, supplements, and anything else.

    7 - Please list any additional medical conditions, surgeries, or hospitalizations you have had.


    • Text box

    8 - Is there anything else related to the treatment that you'd like to ask or discuss with your medical provider?


    • Text box

    9 - Do you have a preferred treatment? *

  • Amoxicillin|(Generic Amoxil®)
    Cephalexin|(Generic Keflex®)
    Nitrofurantoin|(Generic Macrobid®)
    No preference
    • Don't worry if you're not sure. Your doctor will help you pick the best one for you.

    10 - Please enter preferred pharmacy information.


    • Include a complete information where you would like to pick up your medication.

(Only JPEG, JPG, PNG or PDF format allowed and File size should be less than 10MB)

One Time Consulting Charges: $49.99 (USD)

The above payment is for consultation only and does not cover the cost of your medication. Top Health Center will only send your prescription to your pharmacy of choice.

Disclaimer
Yes, I've read the Disclaimer Form.