Are you in one of the following areas in the State of Florida?
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Miami-Dade County
Miami-Dade County
Broward County
Palm Springs County
Brevard County
Port St. Lucie
Osceola Cunty
Orange County
None
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First Name
Last Name
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Email
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Gender
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Date of birth
Height
Weight
How many cigarettes do you smoke per day?
Have you ever been diagnosed with HIV?
Yes
No
Do you currently have a prescription for PrEP?
Yes
No
Name of medication
Name of the Pharmacy managing your prescriptions
Pharmacy phone number
Do you think your current lifestyle puts yourself at risk of HIV?
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Yes
No
Have you ever been diagnosed with the following conditions?
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Gonorrhea
Chlamydia
Syphillis
Hepatitis C
Hepatitis B
Uncontrolled diabetes
Liver Disease
Kidney Disease
None of the above
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Are you currently taking any prescription medications, over the counter drugs or herbal supplements, including supplements on a regular basis?
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Yes
No
Please list all medications you are currently taking
Do you have any drug allergies?
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Yes
No
Please list your known medication allergies
Anything else we should know about your medical history?
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Yes
No
Let us know about any concern you may have!
Please select your insurance plan (select all that apply)
Medicaid
PPO
EPO
HSA
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