PrEP Interest

PrEP Interest

Pre-Exposure Prophylaxis is a once a day medication that can help prevent transmission of HIV. Nebraska AIDS Project remains committed to it's fight against HIV and is now a proud provider of PrEP. Please complete the below interest form if you are interested in learning more.
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Email *
example@example.com
1. Are you currently taking PrEP? *

Yes No
2. How knowledgeable are you about PrEP? *

Very Knowledgeable Moderately Knowledgeable Somewhat Knowledgeable Not at All. What is PrEP?
3. Would you like to learn more about PrEP and NAP’s PrEP program before scheduling an appointment with our medical provider? *

Yes No
4. Best time to contact? *

morning afternoon evening
5. What is your preferred method of contact? *

Phone Email
6. Do you have health insurance? *

Yes No
7. If Yes, what type of insurance *

private employer based medicaid medicare Not applicable
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