{"id":3699,"date":"2024-07-05T17:17:00","date_gmt":"2024-07-05T17:17:00","guid":{"rendered":"https:\/\/hiv-prep.com\/?page_id=3699"},"modified":"2024-07-20T11:24:37","modified_gmt":"2024-07-20T11:24:37","slug":"prep-application-form","status":"publish","type":"page","link":"https:\/\/hiv-prep.com\/zh\/prep-application-form\/","title":{"rendered":"PrEP\/PEP Application Form"},"content":{"rendered":"<div class=\"wp-block-group has-global-padding is-layout-constrained wp-container-core-group-is-layout-3749991f wp-block-group-is-layout-constrained\">\n<p class=\"has-text-color has-small-font-size wp-elements-1 wp-block-paragraph\" style=\"color:#6e6e6eab;margin-bottom:var(--wp--preset--spacing--10)\"><em>* Please ensure you have received a prescription for PrEP\/PEP or negative test results for HIV and Hepatitis B.<br>* If you only have negative test results for HIV and Hepatitis B but no prescription, you will need to purchase our <a href=\"https:\/\/hiv-prep.com\/zh\/product\/online-medical-consultation-services\/\" data-type=\"product\" data-id=\"3327\"><mark style=\"background-color:rgba(0, 0, 0, 0)\" class=\"has-inline-color has-primary-color\">medical consultation service<\/mark><\/a>.<br>* Please ensure you have completed the order and payment before filling out this application form.<\/em><\/p>\n\n\n\n<div class=\"forminator-guttenberg\"><div class=\"forminator-ui forminator-custom-form forminator-custom-form-3674 forminator-design--flat  forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-3674\" data-uid=\"6ad0e76850df1\"><br\/><\/div><form\n\t\t\t\tid=\"forminator-module-3674\"\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-3674 forminator-design--flat  forminator_ajax\"\n\t\t\t\tmethod=\"post\"\n\t\t\t\tdata-forminator-render=\"0\"\n\t\t\t\tdata-form-id=\"3674\"\n\t\t\t\t\n\t\t\t\tdata-design=\"flat\"\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\tdata-grid=\"open\"\n\t\t\t\tenctype=\"multipart\/form-data\"\n\t\t\t\t\n\t\t\t\tstyle=\"display: none;\"\n\t\t\t\t\n\t\t\t\tdata-uid=\"6ad0e76850df1\" action=\"\"\n\t\t\t><div role=\"alert\" aria-live=\"polite\" class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><div class=\"forminator-row\"><div id=\"text-2\" class=\"forminator-field-text forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-text-2_6ad0e76850df1\" id=\"forminator-field-text-2_6ad0e76850df1-label\" class=\"forminator-label\">Your Order Number <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-2\" value=\"\" placeholder=\"\" id=\"forminator-field-text-2_6ad0e76850df1\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><div id=\"email-1\" class=\"forminator-field-email forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-email-1_6ad0e76850df1\" id=\"forminator-field-email-1_6ad0e76850df1-label\" class=\"forminator-label\">You Email Address <span class=\"forminator-required\">*<\/span><\/label><input type=\"email\" name=\"email-1\" value=\"\" placeholder=\"\" id=\"forminator-field-email-1_6ad0e76850df1\" class=\"forminator-input forminator-email--field\" data-required=\"1\" aria-required=\"true\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-3\" class=\"forminator-field-section forminator-col forminator-col-12\"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Basic Information<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-1\" class=\"forminator-field-name forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-name-1_6ad0e76850df1\" id=\"forminator-field-name-1_6ad0e76850df1-label\" class=\"forminator-label\">Full Name (In English) <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-1\" value=\"\" placeholder=\"\" id=\"forminator-field-name-1_6ad0e76850df1\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" aria-describedby=\"forminator-field-name-1_6ad0e76850df1-description\" \/><span id=\"forminator-field-name-1_6ad0e76850df1-description\" class=\"forminator-description\">It must exactly match the name on your official identification documents (e.g. ID Card, Passport, Driver's License, Social Security Card, etc.)<\/span><\/div><\/div><div id=\"name-2\" class=\"forminator-field-name forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-name-2_6ad0e76850df1\" id=\"forminator-field-name-2_6ad0e76850df1-label\" class=\"forminator-label\">Full Name (In official language of your country) <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-2\" value=\"\" placeholder=\"\" id=\"forminator-field-name-2_6ad0e76850df1\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" aria-describedby=\"forminator-field-name-2_6ad0e76850df1-description\" \/><span id=\"forminator-field-name-2_6ad0e76850df1-description\" class=\"forminator-description\">It must exactly match the name on your official identification documents (e.g. ID Card, Passport, Driver\u2019s License, Social Security Card, etc.)<\/span><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-2\" class=\"forminator-field-select forminator-col forminator-col-4\"><div class=\"forminator-field\"><label for=\"forminator-form-3674__field--select-2_6ad0e76850df1\" id=\"forminator-form-3674__field--select-2_6ad0e76850df1-label\" class=\"forminator-label\">Gender <span class=\"forminator-required\">*<\/span><\/label><select id=\"forminator-form-3674__field--select-2_6ad0e76850df1\" class=\"forminator-select--field forminator-select2\" data-required=\"1\" name=\"select-2\" data-default-value=\"\" data-hidden-behavior=\"zero\" data-placeholder=\"Select\" data-search=\"false\" aria-labelledby=\"forminator-form-3674__field--select-2_6ad0e76850df1-label\" aria-describedby=\"forminator-form-3674__field--select-2_6ad0e76850df1-description\"><option value=\"\">Select<\/option><option value=\"one\"  data-calculation=\"0\">Male<\/option><option value=\"two\"  data-calculation=\"0\">Female<\/option><\/select><span id=\"forminator-form-3674__field--select-2_6ad0e76850df1-description\" class=\"forminator-description\">Sex Assigned at Birth<\/span><\/div><\/div><div id=\"date-1\" class=\"forminator-field-date forminator-col forminator-col-4\"><div class=\"forminator-field\"><label for=\"forminator-field-date-1-picker_6ad0e76850df1\" id=\"forminator-field-date-1-picker_6ad0e76850df1-label\" class=\"forminator-label\">Date of birth <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-input-with-icon\"><label for=\"forminator-field-date-1-picker_6ad0e76850df1\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><\/label><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-1\" value=\"\" placeholder=\"\" id=\"forminator-field-date-1-picker_6ad0e76850df1\" class=\"forminator-input forminator-datepicker\" data-required=\"1\" data-format=\"dd\/mm\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" aria-describedby=\"forminator-field-date-1-picker_6ad0e76850df1-description\" \/><\/div><span id=\"forminator-field-date-1-picker_6ad0e76850df1-description\" class=\"forminator-description\">DD\/MM\/YYYY<\/span><\/div><\/div><div id=\"text-9\" class=\"forminator-field-text forminator-col forminator-col-4\"><div class=\"forminator-field\"><label for=\"forminator-field-text-9_6ad0e76850df1\" id=\"forminator-field-text-9_6ad0e76850df1-label\" class=\"forminator-label\">Weight (kg) <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-9\" value=\"\" placeholder=\"\" id=\"forminator-field-text-9_6ad0e76850df1\" class=\"forminator-input forminator-name--field\" data-required=\"1\" aria-describedby=\"forminator-field-text-9_6ad0e76850df1-description\" \/><span id=\"forminator-field-text-9_6ad0e76850df1-description\" class=\"forminator-description\">Must be &gt;35 kg or &gt;77 Ibs to be prescribed PrEP<\/span><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-1\" class=\"forminator-field-address forminator-col forminator-col-4\"><div class=\"forminator-row\" data-multiple=\"false\"><div id=\"address-1-country\" class=\"forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-3674__field--address-1-country_6ad0e76850df1\" id=\"forminator-field-3674__field--address-1-country_6ad0e76850df1-label\" class=\"forminator-label\">Country of Delivery <span class=\"forminator-required\">*<\/span><\/label><select name=\"address-1-country\" id=\"forminator-field-3674__field--address-1-country_6ad0e76850df1\" class=\"forminator-select2\" data-search=\"true\" data-placeholder=\"Select country\" aria-describedby=\"forminator-field-3674__field--address-1-country_6ad0e76850df1-description\" data-default-value=\"\"><option value=\"\" data-country-code=\"\" selected=\"selected\"><\/option><option value=\"Afghanistan\" data-country-code=\"AF\" >Afghanistan<\/option><option value=\"Albania\" data-country-code=\"AL\" >Albania<\/option><option value=\"Algeria\" data-country-code=\"DZ\" >Algeria<\/option><option value=\"American Samoa\" data-country-code=\"AS\" >American Samoa<\/option><option value=\"Andorra\" data-country-code=\"AD\" >Andorra<\/option><option value=\"Angola\" data-country-code=\"AO\" >Angola<\/option><option value=\"Anguilla\" data-country-code=\"AI\" >Anguilla<\/option><option value=\"Antarctica\" data-country-code=\"AQ\" >Antarctica<\/option><option value=\"Antigua and Barbuda\" data-country-code=\"AG\" >Antigua and Barbuda<\/option><option value=\"Argentina\" data-country-code=\"AR\" >Argentina<\/option><option value=\"Armenia\" data-country-code=\"AM\" >Armenia<\/option><option value=\"Australia\" data-country-code=\"AU\" >Australia<\/option><option value=\"Aruba\" data-country-code=\"AW\" >Aruba<\/option><option value=\"Austria\" data-country-code=\"AT\" >Austria<\/option><option value=\"Azerbaijan\" data-country-code=\"AZ\" >Azerbaijan<\/option><option value=\"Bahamas\" data-country-code=\"BS\" >Bahamas<\/option><option value=\"Bahrain\" data-country-code=\"BH\" >Bahrain<\/option><option value=\"Bangladesh\" data-country-code=\"BD\" >Bangladesh<\/option><option value=\"Barbados\" data-country-code=\"BB\" >Barbados<\/option><option value=\"Belarus\" data-country-code=\"BY\" >Belarus<\/option><option value=\"Belgium\" data-country-code=\"BE\" >Belgium<\/option><option value=\"Belize\" data-country-code=\"BZ\" >Belize<\/option><option value=\"Benin\" data-country-code=\"BJ\" >Benin<\/option><option value=\"Bermuda\" data-country-code=\"BM\" >Bermuda<\/option><option value=\"Bhutan\" data-country-code=\"BT\" >Bhutan<\/option><option value=\"Bolivia\" data-country-code=\"BO\" >Bolivia<\/option><option value=\"Bosnia and Herzegovina\" data-country-code=\"BA\" >Bosnia and Herzegovina<\/option><option value=\"Botswana\" data-country-code=\"BW\" >Botswana<\/option><option value=\"Bouvet Island\" data-country-code=\"BV\" >Bouvet Island<\/option><option value=\"Brazil\" data-country-code=\"BR\" >Brazil<\/option><option value=\"British Indian Ocean Territory\" data-country-code=\"IO\" >British Indian Ocean Territory<\/option><option value=\"Brunei\" data-country-code=\"BN\" >Brunei<\/option><option value=\"Bulgaria\" data-country-code=\"BG\" >Bulgaria<\/option><option value=\"Burkina Faso\" data-country-code=\"BF\" >Burkina Faso<\/option><option value=\"Burundi\" data-country-code=\"BI\" >Burundi<\/option><option value=\"Cambodia\" data-country-code=\"KH\" >Cambodia<\/option><option value=\"Cameroon\" data-country-code=\"CM\" >Cameroon<\/option><option value=\"Canada\" data-country-code=\"CA\" >Canada<\/option><option value=\"Cabo Verde\" data-country-code=\"CV\" >Cabo Verde<\/option><option value=\"Cayman Islands\" data-country-code=\"KY\" >Cayman Islands<\/option><option value=\"Central African Republic\" data-country-code=\"CF\" >Central African Republic<\/option><option value=\"Chad\" data-country-code=\"TD\" >Chad<\/option><option value=\"Chile\" data-country-code=\"CL\" >Chile<\/option><option value=\"China, People's Republic of\" data-country-code=\"CN\" >China, People's Republic of<\/option><option value=\"Christmas Island\" data-country-code=\"CX\" >Christmas Island<\/option><option value=\"Cocos Islands\" data-country-code=\"CC\" >Cocos Islands<\/option><option value=\"Colombia\" data-country-code=\"CO\" >Colombia<\/option><option value=\"Comoros\" data-country-code=\"KM\" >Comoros<\/option><option value=\"Congo, Democratic Republic of the\" data-country-code=\"CD\" >Congo, Democratic Republic of the<\/option><option value=\"Congo, Republic of the\" data-country-code=\"CG\" >Congo, Republic of the<\/option><option value=\"Cook Islands\" data-country-code=\"CK\" >Cook Islands<\/option><option value=\"Costa Rica\" data-country-code=\"CR\" >Costa Rica<\/option><option value=\"C\u00f4te d'Ivoire\" data-country-code=\"CI\" >C\u00f4te d'Ivoire<\/option><option value=\"Croatia\" data-country-code=\"HR\" >Croatia<\/option><option value=\"Cuba\" data-country-code=\"CU\" >Cuba<\/option><option value=\"Cura\u00e7ao\" data-country-code=\"CW\" >Cura\u00e7ao<\/option><option value=\"Cyprus\" data-country-code=\"CY\" >Cyprus<\/option><option value=\"Czech Republic\" data-country-code=\"CZ\" >Czech Republic<\/option><option value=\"Denmark\" data-country-code=\"DK\" >Denmark<\/option><option value=\"Djibouti\" data-country-code=\"DJ\" >Djibouti<\/option><option value=\"Dominica\" data-country-code=\"DM\" >Dominica<\/option><option value=\"Dominican Republic\" data-country-code=\"DO\" >Dominican Republic<\/option><option value=\"East Timor\" data-country-code=\"TL\" >East Timor<\/option><option value=\"Ecuador\" data-country-code=\"EC\" >Ecuador<\/option><option value=\"Egypt\" data-country-code=\"EG\" >Egypt<\/option><option value=\"El Salvador\" data-country-code=\"SV\" >El Salvador<\/option><option value=\"Equatorial Guinea\" data-country-code=\"GQ\" >Equatorial Guinea<\/option><option value=\"Eritrea\" data-country-code=\"ER\" >Eritrea<\/option><option value=\"Estonia\" data-country-code=\"EE\" >Estonia<\/option><option value=\"Ethiopia\" data-country-code=\"ET\" >Ethiopia<\/option><option value=\"Falkland Islands\" data-country-code=\"FK\" >Falkland Islands<\/option><option value=\"Faroe Islands\" data-country-code=\"FO\" >Faroe Islands<\/option><option value=\"Fiji\" data-country-code=\"FJ\" >Fiji<\/option><option value=\"Finland\" data-country-code=\"FI\" >Finland<\/option><option value=\"France\" data-country-code=\"FR\" >France<\/option><option value=\"France, Metropolitan\" data-country-code=\"FX\" >France, Metropolitan<\/option><option value=\"French Guiana\" data-country-code=\"GF\" >French Guiana<\/option><option value=\"French Polynesia\" data-country-code=\"PF\" >French Polynesia<\/option><option value=\"French South Territories\" data-country-code=\"TF\" >French South Territories<\/option><option value=\"Gabon\" data-country-code=\"GA\" >Gabon<\/option><option value=\"Gambia\" data-country-code=\"GM\" >Gambia<\/option><option value=\"Georgia\" data-country-code=\"GE\" >Georgia<\/option><option value=\"Germany\" data-country-code=\"DE\" >Germany<\/option><option value=\"Guernsey\" data-country-code=\"GG\" >Guernsey<\/option><option value=\"Ghana\" data-country-code=\"GH\" >Ghana<\/option><option value=\"Gibraltar\" data-country-code=\"GI\" >Gibraltar<\/option><option value=\"Greece\" data-country-code=\"GR\" >Greece<\/option><option value=\"Greenland\" data-country-code=\"GL\" >Greenland<\/option><option value=\"Grenada\" data-country-code=\"GD\" >Grenada<\/option><option value=\"Guadeloupe\" data-country-code=\"GP\" >Guadeloupe<\/option><option value=\"Guam\" data-country-code=\"GU\" >Guam<\/option><option value=\"Guatemala\" data-country-code=\"GT\" >Guatemala<\/option><option value=\"Guinea\" data-country-code=\"GN\" >Guinea<\/option><option value=\"Guinea-Bissau\" data-country-code=\"GW\" >Guinea-Bissau<\/option><option value=\"Guyana\" data-country-code=\"GY\" >Guyana<\/option><option value=\"Haiti\" data-country-code=\"HT\" >Haiti<\/option><option value=\"Heard Island And Mcdonald Island\" data-country-code=\"HM\" >Heard Island And Mcdonald Island<\/option><option value=\"Honduras\" data-country-code=\"HN\" >Honduras<\/option><option value=\"Hong Kong\" data-country-code=\"HK\" >Hong Kong<\/option><option value=\"Hungary\" data-country-code=\"HU\" >Hungary<\/option><option value=\"Iceland\" data-country-code=\"IS\" >Iceland<\/option><option value=\"India\" data-country-code=\"IN\" >India<\/option><option value=\"Indonesia\" data-country-code=\"ID\" >Indonesia<\/option><option value=\"Iran\" data-country-code=\"IR\" >Iran<\/option><option value=\"Iraq\" data-country-code=\"IQ\" >Iraq<\/option><option value=\"Ireland\" data-country-code=\"IE\" >Ireland<\/option><option value=\"Israel\" data-country-code=\"IL\" >Israel<\/option><option value=\"Italy\" data-country-code=\"IT\" >Italy<\/option><option value=\"Jamaica\" data-country-code=\"JM\" >Jamaica<\/option><option value=\"Japan\" data-country-code=\"JP\" >Japan<\/option><option value=\"Jersey\" data-country-code=\"JE\" >Jersey<\/option><option value=\"Johnston Island\" data-country-code=\"JT\" >Johnston Island<\/option><option value=\"Jordan\" data-country-code=\"JO\" >Jordan<\/option><option value=\"Kazakhstan\" data-country-code=\"KZ\" >Kazakhstan<\/option><option value=\"Kenya\" data-country-code=\"KE\" >Kenya<\/option><option value=\"Kiribati\" data-country-code=\"KI\" >Kiribati<\/option><option value=\"Korea, Democratic People's Republic of\" data-country-code=\"KP\" >Korea, Democratic People's Republic of<\/option><option value=\"Korea, Republic of\" data-country-code=\"KR\" >Korea, Republic of<\/option><option value=\"Kosovo\" data-country-code=\"XK\" >Kosovo<\/option><option value=\"Kuwait\" data-country-code=\"KW\" >Kuwait<\/option><option value=\"Kyrgyzstan\" data-country-code=\"KG\" >Kyrgyzstan<\/option><option value=\"Lao People's Democratic Republic\" data-country-code=\"LA\" >Lao People's Democratic Republic<\/option><option value=\"Latvia\" data-country-code=\"LV\" >Latvia<\/option><option value=\"Lebanon\" data-country-code=\"LB\" >Lebanon<\/option><option value=\"Lesotho\" data-country-code=\"LS\" >Lesotho<\/option><option value=\"Liberia\" data-country-code=\"LR\" >Liberia<\/option><option value=\"Libya\" data-country-code=\"LY\" >Libya<\/option><option value=\"Liechtenstein\" data-country-code=\"LI\" >Liechtenstein<\/option><option value=\"Lithuania\" data-country-code=\"LT\" >Lithuania<\/option><option value=\"Luxembourg\" data-country-code=\"LU\" >Luxembourg<\/option><option value=\"Macau\" data-country-code=\"MO\" >Macau<\/option><option value=\"North Macedonia\" data-country-code=\"MK\" >North Macedonia<\/option><option value=\"Madagascar\" data-country-code=\"MG\" >Madagascar<\/option><option value=\"Malawi\" data-country-code=\"MW\" >Malawi<\/option><option value=\"Malaysia\" data-country-code=\"MY\" >Malaysia<\/option><option value=\"Maldives\" data-country-code=\"MV\" >Maldives<\/option><option value=\"Mali\" data-country-code=\"ML\" >Mali<\/option><option value=\"Malta\" data-country-code=\"MT\" >Malta<\/option><option value=\"Marshall Islands\" data-country-code=\"MH\" >Marshall Islands<\/option><option value=\"Martinique\" data-country-code=\"MQ\" >Martinique<\/option><option value=\"Mauritania\" data-country-code=\"MR\" >Mauritania<\/option><option value=\"Mauritius\" data-country-code=\"MU\" >Mauritius<\/option><option value=\"Mayotte\" data-country-code=\"YT\" >Mayotte<\/option><option value=\"Mexico\" data-country-code=\"MX\" >Mexico<\/option><option value=\"Micronesia\" data-country-code=\"FM\" >Micronesia<\/option><option value=\"Moldova\" data-country-code=\"MD\" >Moldova<\/option><option value=\"Monaco\" data-country-code=\"MC\" >Monaco<\/option><option value=\"Mongolia\" data-country-code=\"MN\" >Mongolia<\/option><option value=\"Montserrat\" data-country-code=\"MS\" >Montserrat<\/option><option value=\"Montenegro\" data-country-code=\"ME\" >Montenegro<\/option><option value=\"Morocco\" data-country-code=\"MA\" >Morocco<\/option><option value=\"Mozambique\" data-country-code=\"MZ\" >Mozambique<\/option><option value=\"Myanmar\" data-country-code=\"MM\" >Myanmar<\/option><option value=\"Namibia\" data-country-code=\"NA\" >Namibia<\/option><option value=\"Nauru\" data-country-code=\"NR\" >Nauru<\/option><option value=\"Nepal\" data-country-code=\"NP\" >Nepal<\/option><option value=\"Netherlands\" data-country-code=\"NL\" >Netherlands<\/option><option value=\"Netherlands Antilles\" data-country-code=\"AN\" >Netherlands Antilles<\/option><option value=\"New Caledonia\" data-country-code=\"NC\" >New Caledonia<\/option><option value=\"New Zealand\" data-country-code=\"NZ\" >New Zealand<\/option><option value=\"Nicaragua\" data-country-code=\"NI\" >Nicaragua<\/option><option value=\"Niger\" data-country-code=\"NE\" >Niger<\/option><option value=\"Nigeria\" data-country-code=\"NG\" >Nigeria<\/option><option value=\"Niue\" data-country-code=\"NU\" >Niue<\/option><option value=\"Norfolk Island\" data-country-code=\"NF\" >Norfolk Island<\/option><option value=\"Northern Mariana Islands\" data-country-code=\"MP\" >Northern Mariana Islands<\/option><option value=\"Norway\" data-country-code=\"NO\" >Norway<\/option><option value=\"Oman\" data-country-code=\"OM\" >Oman<\/option><option value=\"Pakistan\" data-country-code=\"PK\" >Pakistan<\/option><option value=\"Palau\" data-country-code=\"PW\" >Palau<\/option><option value=\"Palestine, State of\" data-country-code=\"PS\" >Palestine, State of<\/option><option value=\"Panama\" data-country-code=\"PA\" >Panama<\/option><option value=\"Papua New Guinea\" data-country-code=\"PG\" >Papua New Guinea<\/option><option value=\"Paraguay\" data-country-code=\"PY\" >Paraguay<\/option><option value=\"Peru\" data-country-code=\"PE\" >Peru<\/option><option value=\"Philippines\" data-country-code=\"PH\" >Philippines<\/option><option value=\"Pitcairn Islands\" data-country-code=\"PN\" >Pitcairn Islands<\/option><option value=\"Poland\" data-country-code=\"PL\" >Poland<\/option><option value=\"Portugal\" data-country-code=\"PT\" >Portugal<\/option><option value=\"Puerto Rico\" data-country-code=\"PR\" >Puerto Rico<\/option><option value=\"Qatar\" data-country-code=\"QA\" >Qatar<\/option><option value=\"Reunion Island\" data-country-code=\"RE\" >Reunion Island<\/option><option value=\"Romania\" data-country-code=\"RO\" >Romania<\/option><option value=\"Russia\" data-country-code=\"RU\" >Russia<\/option><option value=\"Rwanda\" data-country-code=\"RW\" >Rwanda<\/option><option value=\"Saint Kitts and Nevis\" data-country-code=\"KN\" >Saint Kitts and Nevis<\/option><option value=\"Saint Lucia\" data-country-code=\"LC\" >Saint Lucia<\/option><option value=\"Saint Vincent and the Grenadines\" data-country-code=\"VC\" >Saint Vincent and the Grenadines<\/option><option value=\"Samoa\" data-country-code=\"WS\" >Samoa<\/option><option value=\"Saint Helena\" data-country-code=\"SH\" >Saint Helena<\/option><option value=\"Saint Pierre & Miquelon\" data-country-code=\"PM\" >Saint Pierre & Miquelon<\/option><option value=\"San Marino\" data-country-code=\"SM\" >San Marino<\/option><option value=\"Sao Tome and Principe\" data-country-code=\"ST\" >Sao Tome and Principe<\/option><option value=\"Saudi Arabia\" data-country-code=\"SA\" >Saudi Arabia<\/option><option value=\"Senegal\" data-country-code=\"SN\" >Senegal<\/option><option value=\"Serbia\" data-country-code=\"RS\" >Serbia<\/option><option value=\"Seychelles\" data-country-code=\"SC\" >Seychelles<\/option><option value=\"Sierra Leone\" data-country-code=\"SL\" >Sierra Leone<\/option><option value=\"Singapore\" data-country-code=\"SG\" >Singapore<\/option><option value=\"Sint Maarten\" data-country-code=\"MF\" >Sint Maarten<\/option><option value=\"Slovakia\" data-country-code=\"SK\" >Slovakia<\/option><option value=\"Slovenia\" data-country-code=\"SI\" >Slovenia<\/option><option value=\"Solomon Islands\" data-country-code=\"SB\" >Solomon Islands<\/option><option value=\"Somalia\" data-country-code=\"SO\" >Somalia<\/option><option value=\"South Africa\" data-country-code=\"ZA\" >South Africa<\/option><option value=\"South Georgia and South Sandwich\" data-country-code=\"GS\" >South Georgia and South Sandwich<\/option><option value=\"Spain\" data-country-code=\"ES\" >Spain<\/option><option value=\"Sri Lanka\" data-country-code=\"LK\" >Sri Lanka<\/option><option value=\"Stateless Persons\" data-country-code=\"XX\" >Stateless Persons<\/option><option value=\"Sudan\" data-country-code=\"SD\" >Sudan<\/option><option value=\"Sudan, South\" data-country-code=\"SS\" >Sudan, South<\/option><option value=\"Suriname\" data-country-code=\"SR\" >Suriname<\/option><option value=\"Svalbard and Jan Mayen\" data-country-code=\"SJ\" >Svalbard and Jan Mayen<\/option><option value=\"Swaziland\" data-country-code=\"SZ\" >Swaziland<\/option><option value=\"Sweden\" data-country-code=\"SE\" >Sweden<\/option><option value=\"Switzerland\" data-country-code=\"CH\" >Switzerland<\/option><option value=\"Syria\" data-country-code=\"SY\" >Syria<\/option><option value=\"Taiwan, Republic of China\" data-country-code=\"TW\" >Taiwan, Republic of China<\/option><option value=\"Tajikistan\" data-country-code=\"TJ\" >Tajikistan<\/option><option value=\"Tanzania\" data-country-code=\"TZ\" >Tanzania<\/option><option value=\"Thailand\" data-country-code=\"TH\" >Thailand<\/option><option value=\"Togo\" data-country-code=\"TG\" >Togo<\/option><option value=\"Tokelau\" data-country-code=\"TK\" >Tokelau<\/option><option value=\"Tonga\" data-country-code=\"TO\" >Tonga<\/option><option value=\"Trinidad and Tobago\" data-country-code=\"TT\" >Trinidad and Tobago<\/option><option value=\"Tunisia\" data-country-code=\"TN\" >Tunisia<\/option><option value=\"Turkey\" data-country-code=\"TR\" >Turkey<\/option><option value=\"Turkmenistan\" data-country-code=\"TM\" >Turkmenistan<\/option><option value=\"Turks And Caicos Islands\" data-country-code=\"TC\" >Turks And Caicos Islands<\/option><option value=\"Tuvalu\" data-country-code=\"TV\" >Tuvalu<\/option><option value=\"Uganda\" data-country-code=\"UG\" >Uganda<\/option><option value=\"Ukraine\" data-country-code=\"UA\" >Ukraine<\/option><option value=\"United Arab Emirates\" data-country-code=\"AE\" >United Arab Emirates<\/option><option value=\"United Kingdom\" data-country-code=\"GB\" >United Kingdom<\/option><option value=\"US Minor Outlying Islands\" data-country-code=\"UM\" >US Minor Outlying Islands<\/option><option value=\"United States of America (USA)\" data-country-code=\"US\" >United States of America (USA)<\/option><option value=\"Uruguay\" data-country-code=\"UY\" >Uruguay<\/option><option value=\"Uzbekistan\" data-country-code=\"UZ\" >Uzbekistan<\/option><option value=\"Vanuatu\" data-country-code=\"VU\" >Vanuatu<\/option><option value=\"Vatican City\" data-country-code=\"VA\" >Vatican City<\/option><option value=\"Venezuela\" data-country-code=\"VE\" >Venezuela<\/option><option value=\"Vietnam\" data-country-code=\"VN\" >Vietnam<\/option><option value=\"Virgin Islands, British\" data-country-code=\"VG\" >Virgin Islands, British<\/option><option value=\"Virgin Islands, U.S.\" data-country-code=\"VI\" >Virgin Islands, U.S.<\/option><option value=\"Wallis And Futuna Islands\" data-country-code=\"WF\" >Wallis And Futuna Islands<\/option><option value=\"Western Sahara\" data-country-code=\"EH\" >Western Sahara<\/option><option value=\"Yemen\" data-country-code=\"YE\" >Yemen<\/option><option value=\"Zambia\" data-country-code=\"ZM\" >Zambia<\/option><option value=\"Zimbabwe\" data-country-code=\"ZW\" >Zimbabwe<\/option><\/select><span id=\"forminator-field-3674__field--address-1-country_6ad0e76850df1-description\" class=\"forminator-description\">Please select the country where you will receive the medicines.<\/span><\/div><\/div><\/div><\/div><div id=\"select-1\" class=\"forminator-field-select forminator-col forminator-col-4\"><div class=\"forminator-field\"><label for=\"forminator-form-3674__field--select-1_6ad0e76850df1\" id=\"forminator-form-3674__field--select-1_6ad0e76850df1-label\" class=\"forminator-label\">Types of Identity Documents <span class=\"forminator-required\">*<\/span><\/label><select id=\"forminator-form-3674__field--select-1_6ad0e76850df1\" class=\"forminator-select--field forminator-select2\" data-required=\"1\" name=\"select-1\" data-default-value=\"\" data-hidden-behavior=\"zero\" data-placeholder=\"Select\" data-search=\"false\" aria-labelledby=\"forminator-form-3674__field--select-1_6ad0e76850df1-label\" aria-describedby=\"forminator-form-3674__field--select-1_6ad0e76850df1-description\"><option value=\"\">Select<\/option><option value=\"two\"  data-calculation=\"0\">National ID Card<\/option><option value=\"one\"  data-calculation=\"0\">Passport<\/option><option value=\"\u793e\u4fdd\u5361\"  data-calculation=\"0\">Residence Permit<\/option><option value=\"\u9a7e\u7167\"  data-calculation=\"0\">Driver's License<\/option><option value=\"Social-Security-Card\"  data-calculation=\"0\">Social Security Card<\/option><\/select><span id=\"forminator-form-3674__field--select-1_6ad0e76850df1-description\" class=\"forminator-description\">Please provide an identity document that can be used to verify your identity in the country where you will receive the medicines.<\/span><\/div><\/div><div id=\"text-1\" class=\"forminator-field-text forminator-col forminator-col-4\"><div class=\"forminator-field\"><label for=\"forminator-field-text-1_6ad0e76850df1\" id=\"forminator-field-text-1_6ad0e76850df1-label\" class=\"forminator-label\">Identity Document\u2019s Number <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-1\" value=\"\" placeholder=\"\" id=\"forminator-field-text-1_6ad0e76850df1\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-2\" class=\"forminator-field-section forminator-col forminator-col-12\"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Health Information<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-18\" class=\"forminator-field-radio forminator-col forminator-col-12  wedith: 30%\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-6ad0e76850df1-label\"><span id=\"forminator-radiogroup-6ad0e76850df1-label\" class=\"forminator-label\">Have you been on PrEP before? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-18-label-1\" for=\"forminator-field-radio-18-1-6ad0e76850df1\" class=\"forminator-radio forminator-radio-inline\" title=\"Currently taking PrEP\"><input type=\"radio\" name=\"radio-18\" value=\"Currently taking PrEP\" id=\"forminator-field-radio-18-1-6ad0e76850df1\" aria-labelledby=\"forminator-field-radio-18-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Currently taking PrEP<\/span><\/label><label id=\"forminator-field-radio-18-label-2\" for=\"forminator-field-radio-18-2-6ad0e76850df1\" class=\"forminator-radio forminator-radio-inline\" title=\"Used to take PrEP, but stopped\"><input type=\"radio\" name=\"radio-18\" value=\"Used to take PrEP, but stopped\" id=\"forminator-field-radio-18-2-6ad0e76850df1\" aria-labelledby=\"forminator-field-radio-18-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Used to take PrEP, but stopped<\/span><\/label><label id=\"forminator-field-radio-18-label-3\" for=\"forminator-field-radio-18-3-6ad0e76850df1\" class=\"forminator-radio forminator-radio-inline\" title=\"Never taken PrEP\"><input type=\"radio\" name=\"radio-18\" value=\"Never-taken-PrEP\" id=\"forminator-field-radio-18-3-6ad0e76850df1\" aria-labelledby=\"forminator-field-radio-18-label-3\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Never taken PrEP<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-8\" class=\"forminator-field-text forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-text-8_6ad0e76850df1\" id=\"forminator-field-text-8_6ad0e76850df1-label\" class=\"forminator-label\">When did you start and stop taking PrEP, and why did you stop? <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-8\" value=\"\" placeholder=\"\" id=\"forminator-field-text-8_6ad0e76850df1\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-6\" class=\"forminator-field-radio forminator-col forminator-col-6  wedith: 30%\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-6ad0e76850df1-label\"><span id=\"forminator-radiogroup-6ad0e76850df1-label\" class=\"forminator-label\">Have you received a prescription for PrEP or PEP from a doctor? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-6-label-1\" for=\"forminator-field-radio-6-1-6ad0e76850df1\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-6\" value=\"Yes\" id=\"forminator-field-radio-6-1-6ad0e76850df1\" aria-labelledby=\"forminator-field-radio-6-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-6-label-2\" for=\"forminator-field-radio-6-2-6ad0e76850df1\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-6\" value=\"No\" id=\"forminator-field-radio-6-2-6ad0e76850df1\" aria-labelledby=\"forminator-field-radio-6-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><div id=\"upload-2\" class=\"forminator-field-upload forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-upload-2_6ad0e76850df1\" id=\"forminator-field-upload-2_6ad0e76850df1-label\" class=\"forminator-label\">Please upload your prescription. <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-file-upload\" data-element=\"upload-2_6ad0e76850df1\" aria-describedby=\"forminator-field-upload-2_6ad0e76850df1-description\"><input type=\"file\" name=\"upload-2\" id=\"forminator-field-upload-2_6ad0e76850df1\" class=\"forminator-input-file-required do-validate\" accept=\".jpg,.jpeg,.jpe,.png,.avif,.css,.htm,.html,.dfxp,.js,.pdf\"><button id=\"forminator-field-upload-2_6ad0e76850df1_button\" class=\"forminator-button forminator-button-upload\" data-id=\"forminator-field-upload-2_6ad0e76850df1\">Choose File<\/button><span data-empty-text=\"No file chosen\">No file chosen<\/span><button class=\"forminator-button-delete\" style=\"display: none;\"><i class=\"forminator-icon-close\" aria-hidden=\"true\"><\/i><span class=\"forminator-screen-reader-only\">Delete uploaded file<\/span><\/button><\/div><span id=\"forminator-field-upload-2_6ad0e76850df1-description\" class=\"forminator-description\">Must be issued within the last two weeks. Only jpg, png, pdf formats accepted.<\/span><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-15\" class=\"forminator-field-radio forminator-col forminator-col-6\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-6ad0e76850df1-label\" aria-describedby=\"forminator-radiogroup-6ad0e76850df1-description\"><span id=\"forminator-radiogroup-6ad0e76850df1-label\" class=\"forminator-label\">What is your HIV test result <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-15-label-1\" for=\"forminator-field-radio-15-1-6ad0e76850df1\" class=\"forminator-radio forminator-radio-inline\" title=\"Positive\"><input type=\"radio\" name=\"radio-15\" value=\"Positive\" id=\"forminator-field-radio-15-1-6ad0e76850df1\" aria-labelledby=\"forminator-field-radio-15-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-radio-15-6ad0e76850df1-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Positive<\/span><\/label><label id=\"forminator-field-radio-15-label-2\" for=\"forminator-field-radio-15-2-6ad0e76850df1\" class=\"forminator-radio forminator-radio-inline\" title=\"Negative\"><input type=\"radio\" name=\"radio-15\" value=\"Negative\" id=\"forminator-field-radio-15-2-6ad0e76850df1\" aria-labelledby=\"forminator-field-radio-15-label-2\" data-calculation=\"0\" checked=\"checked\"  data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-radio-15-6ad0e76850df1-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Negative<\/span><\/label><span id=\"forminator-radiogroup-6ad0e76850df1-description\" class=\"forminator-description\">Note: Only a negative result allows for PrEP\/PEP.<\/span><\/div><\/div><div id=\"upload-3\" class=\"forminator-field-upload forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-upload-3_6ad0e76850df1\" id=\"forminator-field-upload-3_6ad0e76850df1-label\" class=\"forminator-label\">Please upload your HIV test result <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-file-upload\" data-element=\"upload-3_6ad0e76850df1\" aria-describedby=\"forminator-field-upload-3_6ad0e76850df1-description\"><input type=\"file\" name=\"upload-3\" id=\"forminator-field-upload-3_6ad0e76850df1\" class=\"forminator-input-file-required do-validate\" accept=\".jpg,.jpeg,.jpe,.png,.avif,.css,.htm,.html,.dfxp,.js,.pdf\"><button id=\"forminator-field-upload-3_6ad0e76850df1_button\" class=\"forminator-button forminator-button-upload\" data-id=\"forminator-field-upload-3_6ad0e76850df1\">Choose File<\/button><span data-empty-text=\"No file chosen\">No file chosen<\/span><button class=\"forminator-button-delete\" style=\"display: none;\"><i class=\"forminator-icon-close\" aria-hidden=\"true\"><\/i><span class=\"forminator-screen-reader-only\">Delete uploaded file<\/span><\/button><\/div><span id=\"forminator-field-upload-3_6ad0e76850df1-description\" class=\"forminator-description\">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.<\/span><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-16\" class=\"forminator-field-radio forminator-col forminator-col-6\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-6ad0e76850df1-label\"><span id=\"forminator-radiogroup-6ad0e76850df1-label\" class=\"forminator-label\">What is your Hepatitis B test result? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-16-label-1\" for=\"forminator-field-radio-16-1-6ad0e76850df1\" class=\"forminator-radio forminator-radio-inline\" title=\"Positive\"><input type=\"radio\" name=\"radio-16\" value=\"Positive\" id=\"forminator-field-radio-16-1-6ad0e76850df1\" aria-labelledby=\"forminator-field-radio-16-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Positive<\/span><\/label><label id=\"forminator-field-radio-16-label-2\" for=\"forminator-field-radio-16-2-6ad0e76850df1\" class=\"forminator-radio forminator-radio-inline\" title=\"Negative\"><input type=\"radio\" name=\"radio-16\" value=\"Negative\" id=\"forminator-field-radio-16-2-6ad0e76850df1\" aria-labelledby=\"forminator-field-radio-16-label-2\" data-calculation=\"0\" checked=\"checked\"  data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Negative<\/span><\/label><\/div><\/div><div id=\"upload-4\" class=\"forminator-field-upload forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-upload-4_6ad0e76850df1\" id=\"forminator-field-upload-4_6ad0e76850df1-label\" class=\"forminator-label\">Please upload your Hepatitis B test result <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-file-upload\" data-element=\"upload-4_6ad0e76850df1\" aria-describedby=\"forminator-field-upload-4_6ad0e76850df1-description\"><input type=\"file\" name=\"upload-4\" id=\"forminator-field-upload-4_6ad0e76850df1\" class=\"forminator-input-file-required do-validate\" accept=\".jpg,.jpeg,.jpe,.png,.avif,.css,.htm,.html,.dfxp,.js,.pdf\"><button id=\"forminator-field-upload-4_6ad0e76850df1_button\" class=\"forminator-button forminator-button-upload\" data-id=\"forminator-field-upload-4_6ad0e76850df1\">Choose File<\/button><span data-empty-text=\"No file chosen\">No file chosen<\/span><button class=\"forminator-button-delete\" style=\"display: none;\"><i class=\"forminator-icon-close\" aria-hidden=\"true\"><\/i><span class=\"forminator-screen-reader-only\">Delete uploaded file<\/span><\/button><\/div><span id=\"forminator-field-upload-4_6ad0e76850df1-description\" class=\"forminator-description\">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.<\/span><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-9\" class=\"forminator-field-radio forminator-col forminator-col-12\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-6ad0e76850df1-label\"><span id=\"forminator-radiogroup-6ad0e76850df1-label\" class=\"forminator-label\">Have you ever been diagnosed with renal insufficiency? Or kidney problems? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-9-label-1\" for=\"forminator-field-radio-9-1-6ad0e76850df1\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-9\" value=\"Yes\" id=\"forminator-field-radio-9-1-6ad0e76850df1\" aria-labelledby=\"forminator-field-radio-9-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-9-label-2\" for=\"forminator-field-radio-9-2-6ad0e76850df1\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-9\" value=\"No\" id=\"forminator-field-radio-9-2-6ad0e76850df1\" aria-labelledby=\"forminator-field-radio-9-label-2\" data-calculation=\"0\" checked=\"checked\"  data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-8\" class=\"forminator-field-radio forminator-col forminator-col-12\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-6ad0e76850df1-label\"><span id=\"forminator-radiogroup-6ad0e76850df1-label\" class=\"forminator-label\">Have you ever been diagnosed with being at risk for bone fractures or bone loss? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-8-label-1\" for=\"forminator-field-radio-8-1-6ad0e76850df1\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-8\" value=\"Yes\" id=\"forminator-field-radio-8-1-6ad0e76850df1\" aria-labelledby=\"forminator-field-radio-8-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-8-label-2\" for=\"forminator-field-radio-8-2-6ad0e76850df1\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-8\" value=\"No\" id=\"forminator-field-radio-8-2-6ad0e76850df1\" aria-labelledby=\"forminator-field-radio-8-label-2\" data-calculation=\"0\" checked=\"checked\"  data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-3\" class=\"forminator-field-radio forminator-col forminator-col-12  wedith: 30%\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-6ad0e76850df1-label\"><span id=\"forminator-radiogroup-6ad0e76850df1-label\" class=\"forminator-label\">Do you have any known drug allergies? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-3-label-1\" for=\"forminator-field-radio-3-1-6ad0e76850df1\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-3\" value=\"Yes\" id=\"forminator-field-radio-3-1-6ad0e76850df1\" aria-labelledby=\"forminator-field-radio-3-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-3-label-2\" for=\"forminator-field-radio-3-2-6ad0e76850df1\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-3\" value=\"No\" id=\"forminator-field-radio-3-2-6ad0e76850df1\" aria-labelledby=\"forminator-field-radio-3-label-2\" data-calculation=\"0\" checked=\"checked\"  data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-3\" class=\"forminator-field-text forminator-col forminator-col-12  wedith: 70%\"><div class=\"forminator-field\"><label for=\"forminator-field-text-3_6ad0e76850df1\" id=\"forminator-field-text-3_6ad0e76850df1-label\" class=\"forminator-label\">If yes, which drugs? <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-3\" value=\"\" placeholder=\"\" id=\"forminator-field-text-3_6ad0e76850df1\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-4\" class=\"forminator-field-radio forminator-col forminator-col-12\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-6ad0e76850df1-label\"><span id=\"forminator-radiogroup-6ad0e76850df1-label\" class=\"forminator-label\">Do you have any chronic conditions? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-4-label-1\" for=\"forminator-field-radio-4-1-6ad0e76850df1\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-4\" value=\"Yes\" id=\"forminator-field-radio-4-1-6ad0e76850df1\" aria-labelledby=\"forminator-field-radio-4-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-4-label-2\" for=\"forminator-field-radio-4-2-6ad0e76850df1\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-4\" value=\"No\" id=\"forminator-field-radio-4-2-6ad0e76850df1\" aria-labelledby=\"forminator-field-radio-4-label-2\" data-calculation=\"0\" checked=\"checked\"  data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-4\" class=\"forminator-field-text forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-text-4_6ad0e76850df1\" id=\"forminator-field-text-4_6ad0e76850df1-label\" class=\"forminator-label\">If yes, please specify. Are these conditions well-managed? <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-4\" value=\"\" placeholder=\"\" id=\"forminator-field-text-4_6ad0e76850df1\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-10\" class=\"forminator-field-radio forminator-col forminator-col-12\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-6ad0e76850df1-label\" aria-describedby=\"forminator-radiogroup-6ad0e76850df1-description\"><span id=\"forminator-radiogroup-6ad0e76850df1-label\" class=\"forminator-label\">Are you currently taking non-steroidal anti-inflammatory drugs (NSAIDs) or other drugs? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-10-label-1\" for=\"forminator-field-radio-10-1-6ad0e76850df1\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-10\" value=\"Yes\" id=\"forminator-field-radio-10-1-6ad0e76850df1\" aria-labelledby=\"forminator-field-radio-10-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-radio-10-6ad0e76850df1-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-10-label-2\" for=\"forminator-field-radio-10-2-6ad0e76850df1\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-10\" value=\"No\" id=\"forminator-field-radio-10-2-6ad0e76850df1\" aria-labelledby=\"forminator-field-radio-10-label-2\" data-calculation=\"0\" checked=\"checked\"  data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-radio-10-6ad0e76850df1-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><span id=\"forminator-radiogroup-6ad0e76850df1-description\" class=\"forminator-description\">Includes: 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.<\/span><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-5\" class=\"forminator-field-text forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-text-5_6ad0e76850df1\" id=\"forminator-field-text-5_6ad0e76850df1-label\" class=\"forminator-label\">If yes, please specify which medications. <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-5\" value=\"\" placeholder=\"\" id=\"forminator-field-text-5_6ad0e76850df1\" class=\"forminator-input forminator-name--field\" data-required=\"1\" aria-describedby=\"forminator-field-text-5_6ad0e76850df1-description\" \/><span id=\"forminator-field-text-5_6ad0e76850df1-description\" class=\"forminator-description\">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.<\/span><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-14\" class=\"forminator-field-radio forminator-col forminator-col-12\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-6ad0e76850df1-label\"><span id=\"forminator-radiogroup-6ad0e76850df1-label\" class=\"forminator-label\">Are you currently or planning to become pregnant or breastfeeding <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-14-label-1\" for=\"forminator-field-radio-14-1-6ad0e76850df1\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-14\" value=\"Yes\" id=\"forminator-field-radio-14-1-6ad0e76850df1\" aria-labelledby=\"forminator-field-radio-14-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-14-label-2\" for=\"forminator-field-radio-14-2-6ad0e76850df1\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-14\" value=\"No\" id=\"forminator-field-radio-14-2-6ad0e76850df1\" aria-labelledby=\"forminator-field-radio-14-label-2\" data-calculation=\"0\" checked=\"checked\"  data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-13\" class=\"forminator-field-radio forminator-col forminator-col-12\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-6ad0e76850df1-label\"><span id=\"forminator-radiogroup-6ad0e76850df1-label\" class=\"forminator-label\">Do you have any other medical problems the doctor or pharmacist should know? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-13-label-1\" for=\"forminator-field-radio-13-1-6ad0e76850df1\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-13\" value=\"Yes\" id=\"forminator-field-radio-13-1-6ad0e76850df1\" aria-labelledby=\"forminator-field-radio-13-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-13-label-2\" for=\"forminator-field-radio-13-2-6ad0e76850df1\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-13\" value=\"No\" id=\"forminator-field-radio-13-2-6ad0e76850df1\" aria-labelledby=\"forminator-field-radio-13-label-2\" data-calculation=\"0\" checked=\"checked\"  data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-1\" class=\"forminator-field-textarea forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-1_6ad0e76850df1\" id=\"forminator-field-textarea-1_6ad0e76850df1-label\" class=\"forminator-label\">If yes, write them here:<\/label><textarea name=\"textarea-1\" placeholder=\"\" id=\"forminator-field-textarea-1_6ad0e76850df1\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"captcha-1\" class=\"forminator-field-captcha forminator-col forminator-col-12\"><div class=\"forminator-captcha-left forminator-g-recaptcha recaptcha-invisible\" data-theme=\"light\" data-badge=\"inline\" data-sitekey=\"6LfOsvwpAAAAALTzxlt5aNHQyxPd59HqpE8jssv4\" data-size=\"invisible\"><\/div> <\/div><\/div><input type=\"hidden\" name=\"referer_url\" value=\"\" \/><div class=\"forminator-row forminator-row-last\"><div class=\"forminator-col\"><div class=\"forminator-field\"><button class=\"forminator-button forminator-button-submit\">Submit Your Application<\/button><\/div><\/div><\/div><input type=\"hidden\" id=\"forminator_nonce\" name=\"forminator_nonce\" value=\"ebaa273587\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/zh\/wp-json\/wp\/v2\/pages\/3699\" \/><input type=\"hidden\" name=\"form_id\" value=\"3674\"><input type=\"hidden\" name=\"page_id\" value=\"3699\"><input type=\"hidden\" name=\"form_type\" value=\"default\"><input type=\"hidden\" name=\"current_url\" value=\"https:\/\/hiv-prep.com\/zh\/prep-application-form\/\"><input type=\"hidden\" name=\"render_id\" value=\"0\"><input type=\"hidden\" name=\"action\" value=\"forminator_submit_form_custom-forms\"><input type=\"hidden\" name=\"trp-form-language\" value=\"zh\"\/><\/form><\/div>\n<\/div>","protected":false},"excerpt":{"rendered":"<p>* Please ensure you have received a prescription for PrEP\/PEP or negative test results for HIV and Hepatitis B.* If you only have negative test results for HIV and Hepatitis B but no prescription, you will need to purchase our medical consultation service.* Please ensure you have completed the order and payment before filling out [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"no-sidebar","meta":{"footnotes":""},"class_list":["post-3699","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/hiv-prep.com\/zh\/wp-json\/wp\/v2\/pages\/3699","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/hiv-prep.com\/zh\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/hiv-prep.com\/zh\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/hiv-prep.com\/zh\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/hiv-prep.com\/zh\/wp-json\/wp\/v2\/comments?post=3699"}],"version-history":[{"count":20,"href":"https:\/\/hiv-prep.com\/zh\/wp-json\/wp\/v2\/pages\/3699\/revisions"}],"predecessor-version":[{"id":4826,"href":"https:\/\/hiv-prep.com\/zh\/wp-json\/wp\/v2\/pages\/3699\/revisions\/4826"}],"wp:attachment":[{"href":"https:\/\/hiv-prep.com\/zh\/wp-json\/wp\/v2\/media?parent=3699"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}