Novus Services Request

1
Please verify that you are human* This field is required.
2
Select a service
3
Name* This field is required.
First Name
Last Name
4
Birthday* This field is required.
Date
Month
Day
Year
5
Email* This field is required.This 2 step authorization is to prevent spam to this service. If you do not have an email please call the office for an appointment.
example@example.com
Email Verified
The verification code has been sent to some@email.com
Please check your mailbox and paste the code below to complete verification
••••
Didn't receive verification code?or
Receiving the email may take a few minutes, thank you for your patience!
6
Phone Number* This field is required.
Please enter a valid phone number.
7
Preferred Location * This field is required.
Please Select
Please Select
Bethlehem
Bridgeport
Doylestown
Lehighton
Reading
Stroudsburg
8
How did you hear about us?* This field is required.
Facebook
Dating App
Health Dept
Word of mouth
TV Ads
Radio Ads
Other
9
I hereby consent to receive SMS/text messages from Novus Medical Services for the purpose of receiving appointment reminders and related communications. I understand that this is not a condition for receiving medical services. I acknowledge that standard text messaging rates may apply as per my service provider. If I do not wish to receive SMS/text messages, I understand that I can reply "STOP" at anytime to the message system to end all reminders and communications. Please contact the office via telephone if you decline this section to make your appointment request.* This field is required.
I agree to SMS/Text messaging, and understand that I may reply "STOP" to a SMS/Text message at anytime to end enrollment.
10
Do you have symptoms of a STI or have you been exposure to a partner who has been recently diagnosed with a STI?* This field is required.
Yes
No
11
Please select the service(s) you are seeking:* This field is required.
12
What is your preferred language?* This field is required.
English
Spanish
Other
13
Important Info: Appointment requests are processed Monday through Friday. If you require PEP Treatment and it is after our business hours, you should go to the nearest emergency room. PEP Treatment must begin within 72 hours of HIV exposure.
14
Appointment Policy* This field is required.Important Info: Appointment requests are processed Monday through Friday. If you require PEP Treatment and it is after our business hours, you should go to the nearest emergency room. PEP Treatment must begin within 72 hours of HIV exposure.
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