HIV Form

Do you live in Florida?*
- Yes
- No
Which state do you live in?*
We also accept military addresses.
Honesty & Privacy
To ensure the medication we prescribe is safe for you, next please answer a few questions from our medical team. Your answers will be kept confidential, and only used to make sure we provide the right care for you. This telehealth session is not a replacement for a primary care relationship or annual physical wellness exam. We encourage you to see your health provider at least once a year. By starting a consultation, you consent to our Terms of Use, Privacy Policy, & Telehealth Consent Policy.
Email*
Profile
Gender*
- Female
- Male
- Non-binarySex
Date of Birth*
MM slash DD slash YYYY
Height*
Weight*

in lbs
How many cigarettes do you smoke per day?*
- None
- 1-15
- 15+
- 30+
Hidden
Questions
Have you ever been diagnosed with HIV?*
- No
- Yes
Are you currently using PrEP daily?*
- No
- Yes
Are you concerned you may have ongoing risk for HIV or are you thinking of making life changes that may put you at higher risk for HIV?*
- No
- Yes
We’re sorry! It sounds like PrEP may not be necessary at this time. If things in your life change and you feel like you may be at risk for HIV, please get back in touch. We would be happy to help you get on PrEP.
We’re sorry PrEP cannot be prescribed to patients who have already been diagnosed with HIV. HIV is a manageable illness, and we are here to help. If you need help finding HIV medical care near you, just message us at MBALLANTINE@CHCME D.COM.
In the last year, have you been diagnosed with gonorrhea?*
- No
- Yes
Please indicate the areas affected by gonorrhea:*
- None
- Rectum
- Urethra
- Vagina
- Throat
Did you complete treatment for the gonorrhea infection?*
- Yes
- No
- I don't know
Are you concerned you may have ongoing risk for HIV or are you thinking of making life changes that may put you at higher risk for HIV? (Again)*
- Yes
- No
In the last 72 hours, have you been exposed to the semen, vaginal fluid, or blood of someone you know to be HIV positive or is possibly HIV positive?*
- Yes
- No
Was this exposure from a partner who is HIV positive BUT is taking their HIV medications, and whose HIV is currently undetectable?*
- Yes
- No
- I don't know
If you think you have been exposed to HIV within the last 72 hours, we recommend you get PEP, an emergency treatment to prevent HIV infection, before starting PrEP. Your local Emergency Department, Urgent Care Center or STI clinic should be able to provide PEP. Tell them “I had an exposure to HIV and need PEP”
Do you think you may have been exposed to HIV within the last 30 days?*
- Yes
- No
Please go back to => In the last year, have you been diagnosed with gonorrhea?
Do you currently have any of the following flu-like symptoms? (Check all that apply)*
- None
- Sore Throat
- Fevers
- Chills
- Sweats
- Headache
- Muscle Aches and Pains
- Runny Nose
- Swollen Glands
We’re sorry! It sounds like PrEP may not be necessary at this time. If things in your life change and you feel like you may be at risk for HIV, please get back in touch. We would be happy to help you get on PrEP.
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Chlamydia
In the last year, have you been diagnosed with chlamydia?*
- Yes
- No
Please indicate the areas affected by chlamydia:*
- None
- Rectum
- Urethra
- Vagina
- Throat
Did you complete treatment for the chlamydia infection?*
- Yes
- No
In your lifetime, have you ever been diagnosed with syphilis?*
- Yes
- No
Have you ever been diagnosed with any of these conditions? (Check all that apply)*
- No
- Hepatitis C
- Hepatitis B
- Uncontrolled Diabetes
- Kidney Disease
- Liver Disease
What medications are you on for treatment of Hepatitis B?*
- Baraclude
- Emtriva
- Epivir
- Intron A
- Hepsera
- Pegasys
- Vemlidy
- Viread
- Other
Taking anything regularly? Are you currently taking any prescription medications, over the counter drugs or herbal supplements, including St. John's Wort or creatine supplements on a regular basis?*
- Yes
- No
Please list all treatments and drugs:*
Do you have any drug allergies?*
- Yes
- No
Please list your drug allergies and what happens when you use that drug.*
Do you plan to use health insurance to pay for PrEP medication & lab testing?*
- Yes
- No
What type of insurance do you have?*
- Medicaid
- Ppo
- Epo
- Hsa
- Hom or Kaiser
- I don't know what kind of Health Insurance I have.
State Medicaid plans typically cover the full cost of PrEP, we will review the coverage and handle the paperwork for you.
You may qualify for Gilead's Co-Pay Card Gilead's Co-Pay Card provides $7,200 per year towards the cost of Truvada for PrEP - with no monthly cost limit. After checkout, we'll provide additional information on how you can apply.
If you don't have insurance, you may be eligible for Gilead Advancing Access or other programs that cover the full cost of PrEP medication.*
- Sounds Good
Anything else we should know about your medical history?*
- Yes
- No
Tell us about any concerns or questions you have for the medical team.*
Almost there! Just wanted to confirm that by continuing with your request for PrEP, you acknowledge and consent to the ordering and performance of an HIV test. (We need to ask this for legal reasons.) Please visit OUR WEBSITE DISCLAIMER for important information about HIV testing.*
- Yes, I consent to ordering and performance of an Hiv Test.
Assessment complete! Once you finish checkout a member of our medical team will review your request.
Please select "Continue" below to submit your mailing information and we will prepare your test-kit to be mailed out.*
- Continue
Mailing Information Form
Step 1
Please upload a picture of your photo ID.*
Accepted file types: jpg, png, jpeg, Max. file size: 10 MB.
We accept any ID that includes your picture, name, and date of birth. Examples: Driver's License Passport School ID Consular ID.
Step 2
Name*
First Name Last Name
Date of Birth*
MM slash DD slash YYYY
Mailing Address (No PO box allowed)*
Phone Number*
Sign Electronic Consent*
- I consent that CHC can provide their services and communicate with me via mobile phone, messages, e-mail and any kind of online communications, provided that these communications comply with privacy regulations.

Honesty & Privacy

Profile

Questions

Chlamydia

Mailing Information Form

Step 1

Step 2