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SHELL HEALTH

SHELL Health Clinic Registration

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Complete the form below to register for SHELL Health Services.

DO NOT SELECT RETURNING PATIENT UNLESS YOU ARE IN THE LOBBY.

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I am a:
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Gender Identity (Choose all that apply)
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I am:
I am:
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Do you have a copy of your two most recent paystubs?
Do you have an allergy to any medication, prescription or otherwise?
Have you previously been diagnosed with any of following?
On a scale of 1 - 10 (with 10 being always, and 1 being never), how often do you use condoms?
In the last 12 months, have you had VAGINAL sex?
In the last 12 months, have you had ANAL sex?
In the last 12 months, have you had ORAL sex?
In the last 12 months, have you had sex with a MALE?
In the last 12 months, have you had sex with a FEMALE?
In the last 12 months, have you had with someone who is TRANSGENDER or NON-BINARY?
In the last 12 months, have you had sex with MULTIPLE PARTNERS?
In the last 12 months, have you had sex with a MAN who has sex with MEN?
In the last 12 months, have you had sex with someone who is living with HIV?
In the last 12 months, have you had sex with someone who uses INJECTION DRUGS?
In the last 12 months, have you had sex with someone who had an STI?
In the last 12 months, have you had sex with someone while INTOXICATED OR HIGH?
In the last 12 months, have you had sex with someone who has HEMOPHILIA, or has had a TRANSFUSION or TRANSPLANT?
In the last 12 months, have you had sex with someone IN EXCHANGE FOR drugs, money or something you need?
In the last 12 months, have you had sex with SOMEONE WHO EXCHANGES sex for for drugs, money, or something they need?
In the last 12 months, have you had sex with someone of UNKNOWN RISK?

Clinic Hours

Monday: 9am to 4pm

Tuesday:11pm to 7pm

Wednesday: 9am to 4pm

Thursday: 9am to 4pm

Friday: 9am to 4pm

4321 Downtowner Loop N,

Mobile, AL 36609

clinic@shellhealth.org