PrEP/PEP Application Form

Your Order Number *

You Email Address *

Basic Information

Full Name (In English) *It must exactly match the name on your official identification documents (e.g. ID Card, Passport, Driver’s License, Social Security Card, etc.)

Full Name (In official language of your country) *It must exactly match the name on your official identification documents (e.g. ID Card, Passport, Driver’s License, Social Security Card, etc.)

Gender *Sex Assigned at Birth

Date of birth *

DD/MM/YYYY

Weight (kg) *Must be >35 kg or >77 Ibs to be prescribed PrEP

Country of Delivery *Please select the country where you will receive the medicines.

Types of Identity Documents *Please provide an identity document that can be used to verify your identity in the country where you will receive the medicines.

Identity Document’s Number *

Health Information

Have you been on PrEP before? *Currently taking PrEPUsed to take PrEP, but stoppedNever taken PrEP

When did you start and stop taking PrEP, and why did you stop? *

Have you received a prescription for PrEP or PEP from a doctor? *YesNo

Please upload your prescription. *

No file chosen

Must be issued within the last two weeks. Only jpg, png, pdf formats accepted.

What is your HIV test result *PositiveNegativeNote: Only a negative result allows for PrEP/PEP.

Please upload your HIV test result *

No file chosen

Must be issued within the last two weeks. Only jpg, png, pdf formats accepted. If you have engaged in any high-risk behaviors since receiving your negative HIV test result, we recommend that you undergo another HIV test to confirm your negative status before initiating PrEP/PEP medication.

What is your Hepatitis B test result? *PositiveNegative

Please upload your Hepatitis B test result *

No file chosen

Must be issued within the last month. Only jpg, png, pdf formats accepted. Some components of PrEP/PEP are treatments for Hepatitis B. In patients with Hepatitis B who stop PrEP/PEP, this may cause a HepB disease flare. People with HepB infection must have their PrEP/PEP managed by a gastroenterologist or infectious disease specialist.

Have you ever been diagnosed with renal insufficiency? Or kidney problems? *YesNo

Have you ever been diagnosed with being at risk for bone fractures or bone loss? *YesNo

Do you have any known drug allergies? *YesNo

If yes, which drugs? *

Do you have any chronic conditions? *YesNo

If yes, please specify. Are these conditions well-managed? *

Are you currently taking non-steroidal anti-inflammatory drugs (NSAIDs) or other drugs? *YesNoIncludes: Advil/Motrin (ibuprofen), aspirin, Aleve (naproxen). Tenofovir use in conjunction with NSAIDs may increase the risk of kidney damage. Concurrent use is not contraindicated, but patient should be counseled on limiting NSAID use.

If yes, please specify which medications. *Please write down the names of any prescription or over the counter medications or supplements you take. Please include herbal and nutritional products as well. This helps the pharmacist make sure there are no harmful interactions with your PrEP.

Are you currently or planning to become pregnant or breastfeeding *YesNo

Do you have any other medical problems the doctor or pharmacist should know? *YesNo

If yes, write them here: