HIV FORM

Do you live in Florida?

YESNO

Please select your state

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.

Enter Your Email Address:

PROFILE

Gender

MaleFemaleNon-binarySex

Date of Birth

Weight

How many cigarettes do you smoke per day?

None1-1515+30+

Question 1/3: Have you ever been diagnosed with HIV?

NOYES

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@CHCMED.COM

Question 2/3: Are you currently using PrEP daily?

NOYES

Question 3/3: 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?

NOYES

It sounds like you should talk to one of our case managers please email us at: Mballantine@chcmed.com and someone from our team will reach out to you!

Question 3/12: In the last year, have you been diagnosed with gonorrhea?

NOYES

Question 4/14 Please indicate the areas affected by gonorrhea:

NONERECTUMURETHRAVAGINATHROAT

Question 5/14 Did you complete treatment for the gonorrhea infection?

YESNOI DONT KNOW

(AGAIN) Question 3/3: 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?

NOYES

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.

Question 4/17 HIV exposure 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?

NOYES

Question 5/18 Undetectable Partner? Was this exposure from a partner who is HIV positive BUT is taking their HIV medications, and whose HIV is currently undetectable?

NOYES

Question 6/19 PEP recommended

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”

Question 6/18: Do you think you may have been exposed to HIV within the last 30 days?

NOYES

Please check the Question 3/12 again. (In the last year, have you been diagnosed with gonorrhea?)

Question 7/19: Do you currently have any of the following flu-like symptoms?(check all that apply)

NONESORE THROATFEVERSCHILLSSWEATSHEADACHEMUSCLE ACHES OR PAINSRUNNY NOSESWOLLEN GLANDS

Question 4/12: In the last year, have you been diagnosed with chlamydia?

NOYES

Question 9/18: Please indicate the areas affected by chlamydia:

NONERECTUMURETHRAVAGINATHROAT

Question 10/18: Did you complete treatment for the chlamydia infection?

NOYES

Question 9/16: In your lifetime, have you ever been diagnosed with syphilis?

NOYES

Question 12/18: Have you ever been diagnosed with any of these conditions? Check all that apply

NOHEPATITIS CHEPATITIS BUNCONTROLLED DIABETESKIDNEY DISEASELIVER DISEASE

Question 13/19 What medications are you on for treatment of Hepatitis B?

BARACLUDEEMTRIVAEPIVIRINTRON AHEPSERAPEGASYSVEMLIDYVIREADOTHER

Question 13/18: 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?

YESNO

Please list all treatments and drugs:

Question 14/18: Do you have any drug allergies?

YESNO

Please list your drug allergies and what happens when you use that drug.

Question 15/18: Do you plan to use health insurance to pay for PrEP medication & lab testing?

YESNO

Question 13/15: Program eligibility 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

Question 13/15: What type of insurance do you have?

MEDICAIDPPOEPOHSAHOM OR KAISERI DONT KNOW WHAT KIND OF HEALTH INSURANCE I HAVE

State Medicaid plans typically cover the full cost of PrEP, though we recommend calling your plan provider to confirm that Truvada for PrEP is covered.

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.

Question 14/15 Anything else we should know about your medical history?

YESNO

Tell us about any concerns or questions you have for the medical team.

Question 15/15 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 click the link below to submit your mailing information and we will prepare your test-kit to be mailed out.

MAILING INFORMATION FORM

Step 1

Identification

Please upload a picture of your photo ID.
We accept any ID that includes your picture, name, and date of birth.
Examples:Driver's License Passport School ID Consular ID

Do you live in Florida?

Please select your state

HONESTY & PRIVACY

Enter Your Email Address:

PROFILE

Gender

Date of Birth

Weight

How many cigarettes do you smoke per day?

Question 1/3: Have you ever been diagnosed with HIV?

Question 2/3: Are you currently using PrEP daily?

Question 3/3: 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?

Question 3/12: In the last year, have you been diagnosed with gonorrhea?

Question 4/14 Please indicate the areas affected by gonorrhea:

Question 5/14 Did you complete treatment for the gonorrhea infection?

(AGAIN) Question 3/3: 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?

Question 4/17 HIV exposure 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?

Question 5/18 Undetectable Partner? Was this exposure from a partner who is HIV positive BUT is taking their HIV medications, and whose HIV is currently undetectable?

Question 6/19 PEP recommended

Question 6/18: Do you think you may have been exposed to HIV within the last 30 days?

Question 7/19: Do you currently have any of the following flu-like symptoms?(check all that apply)

Question 4/12: In the last year, have you been diagnosed with chlamydia?

Question 9/18: Please indicate the areas affected by chlamydia:

Question 10/18: Did you complete treatment for the chlamydia infection?

Question 9/16: In your lifetime, have you ever been diagnosed with syphilis?

Question 12/18: Have you ever been diagnosed with any of these conditions? Check all that apply

Question 13/19 What medications are you on for treatment of Hepatitis B?

Question 13/18: 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?

Please list all treatments and drugs:

Question 14/18: Do you have any drug allergies?

Please list your drug allergies and what happens when you use that drug.

Question 15/18: Do you plan to use health insurance to pay for PrEP medication & lab testing?

Question 13/15: What type of insurance do you have?

Question 14/15 Anything else we should know about your medical history?

Tell us about any concerns or questions you have for the medical team.

Question 15/15 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

MAILING INFORMATION FORM

Step 1

Identification

Please upload a picture of your photo ID.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

Date Of Birth:

MAILING ADDRESS (NO PO BOX ALLOWED)

PHONE NUMBER

SIGN ELECTRONIC CONSENTS FORMS

Please upload a picture of your photo ID.
We accept any ID that includes your picture, name, and date of birth.
Examples:Driver's License Passport School ID Consular ID