Novus TelePrEP

1
Do you currently live in Pennsylvania?* This field is required.
YESNO
2
We're sorry! At this time Novus TelePrEP is only offered to people living in Pennsylvania. We're working hard to add to our services, until please visit our offices or www.preplocator.org
3
What type of insurance do you have?* This field is required.Please note some patients have co-pays that are due at time of service
Private Insurance
Medicaid/Medicare
4
Consent for testing HIV, Notice of Practice Privacy Policy, Privacy, Telehealth consent, Terms of Use for TelehealthPlease review before continuing.
5
Terms and Conditions* This field is required.I have read and understand the documents and consents to Telehealth, Telehealth Terms of Use, Privacy, Notice of Practice Privacy Policy, HIV and or STI testing.
6
Full Name.* This field is required.Please enter your full legal name as it appears on your ID and Insurance cards
First Name
Middle Name
Last Name
7
Date of Birth* This field is required.
Date
Month
Day
Year
8
Address* This field is required.Please enter your current address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
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Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
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Northern Mariana
Norway
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Palau
Palestine
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Paraguay
Peru
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Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
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Saint Lucia
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Samoa
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Senegal
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South Ossetia
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eSwatini
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Zimbabwe
Other
Country
9
Email* This field is required.We'll need an email to complete the set up of your patient account
example@example.com
10
Cell phone number* This field is required.We do sent reminders via SMS/text message
Please enter a valid phone number.
11
Since we got your digits, is it cool if we text you?* This field is required.I, the User, by using the Novus TelePrEP Service (referred to as the Service herein), you consent to receiving electronic communications from us. These communications may include notices about your account and information concerning or related to the Service. You agree that any notices, agreements, disclosures, or other communications that we send to you electronically will satisfy any legal communication requirements, including that such communications be in writing. You are solely responsible for all fees charged by your telecommunications service provider, or any other service provider related to your use of the Service, including without limitation, any SMS / text messaging fees, data charges, and other fees. These terms are the entire agreement between you and Novus Medical Services regarding your use of the Service. Contact Novus Medical Services for questions, comments, complaints, or claims related to the Service at 1565 Linden Street, Bethlehem, PA 18017 (610)867-5365 or mobileunit@novusacs.com
Clear
12
Please take a photo of the FRONT of your insurance card.* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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13
ID number from Insurance Card* This field is required.
14
Please take a photo of the BACK of your insurance card.* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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15
Please take a photo of the front of your Photo ID Card.* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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16
What was your assigned gender at birth?* This field is required.
Female
Male
17
What gender do you currently identify with?* This field is required.
Male
Female
Non-Binary
Transgender Male to Female
Transgender Female to Male
18
What sexual orientation do you currently identify with?* This field is required.
Male who has sex with Males
Male who has sex with Females
Females who has sex with Males
Females who has sex with Females
Bisexual
Pansexual
19
Have you been diagnosed as a person living with HIV?* This field is required.
YESNO
20
We're sorry, currently we're only offering online PrEP for HIV care. We will be adding online HIV care to our services in the near future. Please contact the closest Novus Medical Services office to obtain care for HIV.

Call us at (610)867-5365 or visit at

www.novusacs.com
21
Have you been exposed to HIV within the last 72 hours?* This field is required.Unprotected sex, with a person(s) whom you don't know their HIV status.
YESNO
22
This is an emergency situation, but stay calm you got this. If you have been exposed to HIV within the last 72 hours, you need to go to the closest Emergency Room, Novus Medical Services Office, or another STI clinic and request PEP (Post Exposure Prophylaxis) as soon as possible.

If you need to talk to someone please call us at (610)867-5365 for more information.
23
Do you receive vaginal intercourse?* This field is required.Everything counts!
YESNO
24
Do you have anal sex?* This field is required.Any type of play counts!
YESNO
25
What are you into? Just asking in a professional manner of course!* This field is required.Pick as many as you like!
Top Only
Versatile/Switch
Bottom Only
Rimming
Oral
Toys
Mutual Masturbation
Solo
Other
26
How many sexual partners have you had in the last 3 months?* This field is required.Any kind of sex involving another person.
27
Have you had an HIV test in the past?* This field is required.
YESNO
28
What was the results of your HIV test?* This field is required.
Negative
Positive
Indeterminate
29
We're sorry if you tested positive for HIV, we're currently not offering online care yet, but we plan to be soon! If you received indeterminate results from an HIV test, then we would like to see you in office. Please visit our website at www.novusacs.com to contact the closest office. Thank you!
30
Have you ever been diagnosed with syphilis in the past?* This field is required.Syphilis is a bacterial sexually transmitted infection, typically it is treated with a very large needle. It is not Chlamydia or Gonorrhea.
YESNO
31
Submission Number
32
Great, we're all done with the personal questions! All we need is some lab work completed on you to move forward, we have 2 options for you.* This field is required.
Lab testing - We'll email you a lab slip, and you go to your insurance carrier's preferred lab (Quest, Labcorp, etc) and have the lab work completed there. PS- You'll have to wear clothes at the lab, they want us to tell you that.
Coming Soon! - 2023 (At-home testing - We mail you a kit, you prick your fingers, and send some blood back to us! Do it in the nude or your PJ's, we don't care!)
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