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Submitted URL:
http://rs.ashwellatx.org/rs/a0u_iPUq
Effective URL:
https://www.ashwellatx.org/make-an-appointment?utm_source=Email%20Media@&utm_medium=RocketseedUSAReseller&utm_campaign=ASHw...
Submission: On October 04 via api (October 4th 2021, 2:32:16 pm UTC) from US — Scanned from DE

Form analysis
1 forms found in the DOM

Name: wf-form-Contact-Form —

<form id="wf-form-Contact-Form" name="wf-form-Contact-Form" data-name="Contact Form" class="form-grid">
  <div><label class="field-label">Appointment Type (Select one)</label><label class="w-checkbox checkbox-field-2"><input type="checkbox" id="Prep Initial Appointment" name="Prep-Initial-Appointment" data-name="Prep Initial Appointment"
        class="w-checkbox-input"><span for="Prep Initial Appointment" class="checkbox-label-2 w-form-label">PrEP Initial Appointment</span></label><label class="w-checkbox"><input type="checkbox" id="PrEP Follow Up" name="PrEP-Follow-Up"
        data-name="PrEP Follow Up" class="w-checkbox-input"><span for="PrEP Follow Up" class="checkbox-label-2 w-form-label">PrEP Follow Up</span></label><label class="w-checkbox"><input type="checkbox" id="PEP" name="PEP" data-name="PEP"
        class="w-checkbox-input"><span for="PEP" class="checkbox-label-2 w-form-label">PEP</span></label><label class="w-checkbox"><input type="checkbox" id="HIV Care" name="HIV-Care" data-name="HIV Care" class="w-checkbox-input"><span for="HIV Care"
        class="checkbox-label-2 w-form-label">HIV Care</span></label><label class="w-checkbox"><input type="checkbox" id="Hepatitis C Care" name="Hepatitis-C-Care" data-name="Hepatitis C Care" class="w-checkbox-input"><span for="Hepatitis C Care"
        class="checkbox-label-2 w-form-label">Hepatitis C Care</span></label></div>
  <div><label class="field-label">Supportive Services (Select any additional services needed)</label><label class="w-checkbox"><input type="checkbox" id="STI Testing and/or Treatment" name="STI-Testing-and-or-Treatment"
        data-name="STI Testing and/or Treatment" class="w-checkbox-input"><span for="STI Testing and/or Treatment" class="checkbox-label-2 w-form-label">STI Testing and/or Treatment</span></label><label class="w-checkbox"><input type="checkbox"
        id="Gender Care (HRT/gender consultation)" name="Gender-Care-HRT-gender-consultation" data-name="Gender Care (HRT/gender consultation)" class="w-checkbox-input"><span for="Gender Care (HRT/gender consultation)"
        class="checkbox-label-2 w-form-label">Gender Care (HRT/gender consultation)</span></label><label class="w-checkbox"><input type="checkbox" id="Pap Smear/Wellness Exam" name="Pap-Smear-Wellness-Exam" data-name="Pap Smear/Wellness Exam"
        class="w-checkbox-input"><span for="Pap Smear/Wellness Exam" class="checkbox-label-2 w-form-label">Pap Smear/Wellness Exam</span></label></div>
  <div><label class="field-label">Preference for Provider</label><label class="w-checkbox"><input type="checkbox" id="Provider Preference (None)" name="Provider-Preference-None" data-name="Provider Preference (None)" class="w-checkbox-input"><span
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        data-name="Provider Preference (Male)" class="w-checkbox-input"><span for="Provider Preference (Male)" class="checkbox-label-2 w-form-label">Male</span></label><label class="w-checkbox"><input type="checkbox" id="Provider Preference (Female)"
        name="Provider-Preference-Female" data-name="Provider Preference (Female)" class="w-checkbox-input"><span for="Provider Preference (Female)" class="checkbox-label-2 w-form-label">Female</span></label></div>
  <div><label class="field-label">Language</label><label class="w-checkbox"><input type="checkbox" id="English" name="English" data-name="English" class="w-checkbox-input"><span for="English"
        class="checkbox-label-2 w-form-label">English</span></label><label class="w-checkbox"><input type="checkbox" id="Spanish" name="Spanish" data-name="Spanish" class="w-checkbox-input"><span for="Spanish"
        class="checkbox-label-2 w-form-label">Spanish</span></label></div>
  <div><label class="field-label">Transportation</label><label class="w-checkbox"><input type="checkbox" id="Transportation Assistance" name="Transportation-Assistance" data-name="Transportation Assistance" class="w-checkbox-input"><span
        for="Transportation Assistance" class="checkbox-label-2 w-form-label">Would you like transportation assistance to your appointment?</span></label></div>
  <div><label for="name" class="field-label">Your Name <span class="text-alert">*</span></label><input type="text" class="form-input w-input" maxlength="256" name="name" data-name="Name" id="name"></div>
  <div><label for="Phone" class="field-label">Contact Number <span class="text-alert">*</span></label><input type="tel" class="form-input w-input" maxlength="256" name="Phone" data-name="Phone" id="Phone" required=""></div>
  <div><label for="Message" class="field-label">Message <span class="text-alert">*</span></label><textarea name="Message" maxlength="5000" id="Message" data-name="Message" required="" class="form-input text-area-input w-input"></textarea></div><input
    type="submit" value="Send Message" data-wait="Please wait..." class="button w-button">
</form>

Text Content

HomeServicesOur StorySupport Our WorkBlogAddress and Contact

Get a MaskCOVID-19 UpdateJoin Our TeamLegal
Copyright © 2020 Ashwell Clinic


Request an Appointment



REQUEST AN APPOINTMENT

Be aware, ASHwell currently has limited STI testing capacity for persons who are
not full-time PrEP, HIV, or Hep C patients at ASHwell.

IF YOU ARE SEEKING STI TESTING: ASHwell is hosting a FREE STI testing event this
Saturday, September 25th at Sir Rat Leather located at 2605 E Cesar Chavez. It
is from 4:30 - 7:30 PM and is OPEN TO ALL. Austin Public Health will be testing
for HIV, gonorrhea, chlamydia, and syphilis and linking to treatment if needed.
Appointment Type (Select one)PrEP Initial AppointmentPrEP Follow UpPEPHIV
CareHepatitis C Care
Supportive Services (Select any additional services needed)STI Testing and/or
TreatmentGender Care (HRT/gender consultation)Pap Smear/Wellness Exam
Preference for ProviderNo PreferenceMaleFemale
LanguageEnglishSpanish
TransportationWould you like transportation assistance to your appointment?
Your Name *
Contact Number *
Message *
Thank you! Your submission has been received!
Oops! Something went wrong while submitting the form.

AUSTIN LOCATION

3100 Red River
Suite 105
Austin TX 78705



CLINIC HOURS

Monday
5pm - 7:30pm
‍
Tuesday
12pm - 3:30pm
‍
Wednesday
11am - 3:30pm, 5pm - 7pm
‍
Thursday
11am - 3pm
‍
Friday
10am - 1:30pm

CLINIC HOURS

Sundays
12-3:30 PM


Administrative Office and Case Management
‍
3208 Red River, Suite 300
Austin, TX 78705

3100 Red River Suite 3, Austin TX 78705
(512) 467 0088
English
 * Español

www.ashwellatx.org Open in urlscan Pro 52.49.198.28 Public Scan

Form analysis 1 forms found in the DOM

Name: wf-form-Contact-Form —

Text Content

www.ashwellatx.org Open in urlscan Pro
52.49.198.28 Public Scan

Form analysis
1 forms found in the DOM