Referral - Ryan White Intake

HIV Care Services

HIV Medical Care | Ryan White Program Enrollment
Your Information

Please complete the following to request an appointment with an ARcare case manager to discuss HIV care services. Your information is strictly kept confidential.
IMPORTANT: If you are currently experiencing a medical emergency or think you were exposed to HIV within the last 72 hours, please seek immediate care at your local emergency room or urgent care facility.
Today's Date*

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Date
Your Name (First and Last)*
Date of Birth*

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Date
Age*
City of Residence*
State *
Preferred Method of Contact*

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Your Email Address*
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Phone Number*
Appointment Location*
How did you hear about us?*

Google/Online SearchARcare WebsiteFacebookDating AppEventBrochure/BookletFriendARcare StaffOther
Additional Comments
By signing below, I give my consent to be contacted by an ARcare team member to help schedule my appointment.
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HIV Care Services