San Antonio AIDS Foundation PrEP Referral Form

Let's Get You PrEP'd and Doxy Ready!

Please complete the form and a PrEP Nevigator will contact you.
Thank You for Your Interest in PrEP!

We’re glad you’re taking this step toward protecting your health.
Our PrEP Navigator will be with you every step of the way to guide you through the process of getting on PrEP.

Please fill out the form below to get started.
What is PrEP?

PREEXPOSURE PROPHYLAXIS

PrEP (pre-exposure prophylaxis) is a daily prevention pill for HIV-negative people who are especially vulnerable to contracting HIV. When taken daily, PrEP is up to 99% effective in preventing HIV.
Please read before continuning with the referral

PrEP Program Info

Lab appointments:

Monday–Friday, 8:30 a.m. – 4:00 p.m.

Provider appointments are limited and happen on:

Mondays
Tuesday afternoons
Wednesdays
Thursday mornings

The clinic is closed weekends and takes lunch from 12:00 – 1:00 p.m

To stay on PrEP, you’ll need two appointments every 3 months:
1. Lab appointment
2. Provider visit (1–2 weeks after labs)
PrEP medication is prescribed during the provider visit.
How did you hear about SAAF's PrEP program:*
Who was your tester during your testing session?
Preferred language:*

EnglishSpanishOther
I am filling out this form because:*

I am ready to start PrEP.I am interested in receiving more information regarding PrEP.
If you have any questions regarding PrEP, please write your questions below and a PrEP Navigator can assist you.
What is your legal name:*

First NameMiddle NameLast Name
Preferred name:
Date of Birth:*

MonthDayYear
Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number:*
Please enter a valid phone number.
Email:
example@example.com
How would you like to be contacted:*

TextEmailPhone
Sex: (Assigned at birth)*

MaleFemale
Gender:*

Cisgender MaleCisgender FemaleTrans ManTrans WomanNonbinaryOther
Identify as:*

GayStraighBisexualLesbianQueerNot listed
Race(s):*

WhiteBlackAsianPacific IslanderAmerican IndianNot listed
Hispanic/Latino:*

YesNo
Employed:*

YesNo
Health Insurance:*

YesNo
If yes, who is your Health insurance provider?
Please provide a clear picture of your I.D.
Identification
Please provide a clear picture or upload your Health Insurance

Prior to scheduling, your insurance would need to be verified.
Health insurance front
Health insurance back
Health insurance Upload

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Health insurance Upload

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If you don't have Health insurance please answer the following questions
What is your monthly income?
What is your household dependents? (a dependent is a child or a relative that you provide for. Consider yourself to be a dependent)
BY SIGNING BELOW, YOU AGREE TO THE FOLLOWING COMMITMENTS TO YOURSELF AND THE PrEP PROGRAM:
1. Complete laboratory testing.
2. Attend a follow-up appointment with the PrEP provider after completing your lab tests.
3. Take PrEP medication as prescribed.
Signature*

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BY SIGNING BELOW, I CONSENT TO BE CONTACTED ABOUT PREP MANAGEMENT AND AGREE TO HAVE MY PREP NAVIGATOR FILL OUT PREP ASSISTANCE PROGRAMS AND SIGN RELATED CONSENT FORMS ON MY BEHALF IF NEEDED.
Signature*

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Let's Get You PrEP'd and Doxy Ready!

What is PrEP?

PREEXPOSURE PROPHYLAXIS

Please provide a clear picture or upload your Health Insurance

If you don't have Health insurance please answer the following questions