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Get Help Finding, Starting, or Staying on PrEP!
Please provide the following basic information and a member of our team will reach out with next steps to connect you to PrEP care in Arkansas.
First and Last Name
*
First Name
Last Name
Preferred Language
*
English
Spanish
Gender
*
Female
Male
Transgender
Other
Phone Number
*
-
Area Code
Phone Number
Are you able to receive text messages at this phone number?
*
Yes
No
E-mail
*
Please provide your address to help us understand what area of the state you live in. When we receive your request, we will do our best to connect you to a community partner offering PrEP services in your local community.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How long has it been since your last HIV test?
*
Less than 1 month
2-6 months
7-12 months
More than 12 months
I have never been tested
Which best describes your knowledge or use of PrEP (Pre-Exposure Prophylaxis?
*
I do not know about PrEP.
I have taken PrEP sometimes.
I have taken on-demand PrEP around sexual activity.
I have heard of PrEP, but never taken it.
I used to take PrEP once a day as prescribed.
I was taking PrEP, but am not now.
Other
How did you learn about PrEPared for Life?
*
Brochure or Printed Material
Dating App (Grindr, Scruff, Tindr)
Facebook or Instagram
Google or Online Search
Podcast
Referred by friend
Referred by staff at EAC
Special Event
Website - Arkansas Resource Hub
Website - Engaging Arkansas Communities
Other
Submit
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