Club Dallas Testing Request Form

Welcome to Prism Health North Texas!

For your health, this testing service will include a brief phone call and in-person testing for sexually transmitted infections (STI’s).

This service is FREE and confidential (testing options are available to meet most needs).

Please complete the following form.

Legal Name*
First Last
Preferred Name
Preferred Language
Date of Birth*
Month
Day
Year
Assigned Sex at Birth*
Are You Transgender?*
Race*
City and Zip Code*
City ZIP Code
Phone*
Email*
Security Question - What is your favorite color?*
We will ask this question at the start of our call to confirm it's you.
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