Medical Information Form to Get Your PrEP Prescription.

We’d love to make this form shorter, but everything we ask is required to provide your PrEP!

And, it only takes a minute or two for you to get your PrEP prescription delivered to your door! We’re here to make it easy, so don’t hesitate to contact us.

This is information is kept confidential to the doctor and pharmacist.

Legal Name for Prescription

First Name

Last Name

Date of Birth

YYYY

Cell Phone Number

If the Pharmacist needs to text you to confirm any information

(###)

###

####

Mailing Address For PrEP Delivery

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Do you have prescription insurance?

If using insurance, please provide these #s, if you have them, from your insurance card

Insurance ID #

Bin #

Group #

PCN #

Sex at Birth

Gender Identity

Have you been diagnosed with HIV?

In the last 72 hours, have you been exposed to Semen or Blood of Anyone Who is HIV Positive?

Have you ever been diagnosed with any of the following?

Do any of the following apply to you?

Have you ever or currently taking PrEP?

Do you have any drug allergies?

Do you have any questions or is there anything else we should know about your health?

Please list any current medications for the Pharmacist.