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
Submit
Should be Empty: