• Pre-Exposure Prophylaxis (PrEP) Intake Form

    CONFIDENTIAL - PROTECTED HEALTH INFORMATION

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  • Background Information

    These questions are highly confidential and help the pharmacist to determine if PrEP is right for you and what Human Immunodeficiency Virus (HIV) and Sexually Transmitted Infection (STI) testing is recommended
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  • Medical History

  • Testing and Treatment

  • I must get an HIV test every 90 days to get my PrEP prescription filled. Per the CDC, the pharmacist must document a negative HIV test to fill my PrEP prescription. 

    • I may be able to have tests performed at the pharmacy 
    • I can bring in my HIV test results, showing negative HIV and/or STI testing, within the last 2 weeks
    • I understand that if I have condomless sex within 2 weeks before and between the time I get my HIV test and when I get my PrEP that the test results may not be accurate. This could lead to PrEP drug resistance if I become HIV positive and I will need a repeat HIV test within one month 

  • I understand that I must complete STI screening at least every 6 months while on PrEP. Undiagnosed STI's will increase the risk of HIV.

    • I understand that if I have condomless sex between the time I get my STI testing and when I get my PrEP that the test results may not be accurate. 

    I understand that the effectiveness of PrEP is dependent on my taking all my doses. Missing doses increases the risk of getting HIV

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