Are you in one of the following areas in the State of Florida?

Have you ever been diagnosed with HIV?

Yes

First Name

Last Name

Address

Street Address

City

State

Country

Postal Code

Email *

Phone *

By providing your contact information, you agree to receive text messages and phone calls (including automated, pre-recorded, or AI voice calls) from us regarding your PrEP consultation appointment and related marketing communications. Message and data rates may apply. You may opt out at any time by replying STOP to text messages or requesting removal during a call.

Gender

Height

Weight

Do you have any drug allergies?

Yes

Do you currently have an active medical insurance plan?

Are you currently taking any prescription medications, over the counter drugs or herbal supplements, including supplements on a regular basis?

Yes

Anything else we should know about your medical history?

Yes