Berkeley Free Clinic | Saturday Services: Remote Appointment Request Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

CURRENT HOURS: Saturdays, 10:00 am - 12:00 pm

The Saturday Services Section offers free services to folx who identify as women, trans, and/or gender non-conforming. We, unfortunately, do not see clients who identify as cisgender male but can direct you towards other sections that do.

-----------------------------------------------------

FOR FOLX WHO DO NOT HAVE ANY UTI OR UROGENITAL SYMPTOMS:
If you are interested in screening for STIs, please continue filling out this form. We will contact you for a VIRTUAL sexual health counseling appointment for this upcoming Saturday. Appointments will be conducted either as a phone call or video meeting. Your remote appointment may take between 30-60 minutes depending on your needs. During the appointment, you will receive instructions about going to a lab facility (LabCorp) for urine/blood collection.

We guarantee that we will contact all clients on Saturday between 10:00 am and 12:00 pm who have completed this form by Friday at 8:00 pm. If you submit this form on Saturday, you will be contacted the next Saturday unless our capacity permits otherwise.

-----------------------------------------------------

FOR FOLX WHO HAVE UTI OR UROGENITAL SYMPTOMS:
We offer in-person evaluation and treatment for individuals with symptoms during select weekends of the month. If you are interested in an IN-PERSON appointment, please continue filling out this form and specify the symptoms you are experiencing. During your appointment, we will meet you at the Berkeley Free Clinic (2339 Durant Ave, Berkeley, CA 94704) to conduct the appropriate tests and exams. These appointments may take up to 1-2 hours.

Current schedule for in-person appointments:
July 2022: July 23rd

If you fill out this form within a week of the dates above, we will reach out to you to schedule an in-person appointment. Please understand that depending on the severity/ timing of your symptoms and our capacity, we may not be able to see you. We will communicate this with you and do our best to answer questions/ provide referral recommendations as needed.

Are you currently experiencing any urogenital symptoms? *

Yes, I am currently experiencing urogenital symptoms and will indicate them in the next question.

No, I am not currently experiencing any urogenital symptoms.

Which of the following urogenital symptoms are you experiencing?

Back pain, at bottom of rib cage

Fever, chills, and/or night sweats

Nausea and vomiting

Frequent urination

Pain on urination

Pain during sex

Unusual genital discharge

Unusual bumps/sores in genital region

Spotting between menstrual periods

Unusual cramping

Scheduling an Appointment: While we may still see clients who have urogenital symptoms, please know that we may refer you out if your symptoms are beyond the scope of our care. Would you like to move forward with scheduling an appointment? *

N/A: I am not experiencing any urogenital symptoms.

Yes, I recognize that I may be referred out if my urogenital symptoms are beyond the scope of care I may receive at Saturday Services, and I would like move forward with signing up for a Saturday Services appointment.

No, I will not be scheduling an appointment. ** Here is a link for medical orgs/resources open during shelter-in-place: https://bayareacommunityresources.wikia.org/wiki/Medical_Orgs/Resources_Open_During_Shelter-In-Place **

Clear form

Never submit passwords through Google Forms.

This form was created inside of Berkeley Free Clinic. Report Abuse

Forms