Intake form

Help us serve you better

Name *

Email address *

What is your age?

What is your gender identity?

What is your sexual orientation?

Do you have any specific health concerns or symptoms?

How did you hear about SWING silom polyclinic?

Which service or services are you interested in?

Please select at least one option.

Anti-HIV 4th generation testing

TPHA syphilis / RPR testing

RPR titer testing

Hepatitis C virus testing (Anti-HCV)

Hepatitis B virus testing (HBsAg)

CD4 count testing

HIV viral load testing

STI testing and treatment

RPR titer

Additional questions or comments

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SWING Silom Polyclinic