SAAF PrEP Referral Form (Testing)

Thank You for Your Interest in PrEP
We’re glad you’re taking this important step to protect your health.
Please complete the form, and a PrEP Navigator will contact you within 1–2 business day

What You Need to Know

1. INSTI HIV Requirement

Before starting PrEP, you will be required to complete a rapid HIV test (INSTI HIV-1/2) at our testing department.
PrEP can only be started after a confirmed negative HIV test result.
If HIV testing has not been completed or is reactive, PrEP will not be initiated.

2. What is PrEP

PrEP (Pre-Exposure Prophylaxis) is a safe and highly effective medication that prevents HIV. It is for people who are HIV-negative and want to reduce their risk of getting HIV.

3. Forms of PrEP

Daily Pill – taken once daily, up to 99% effective when taken correctly
Injectable PrEP (Every 2 Months) – long-acting injection given in clinic
Injectable PrEP (Every 6 Months) – newer long-acting option given twice per year

4. Doxy PEP

Doxy PEP may be discussed during your provider visit if appropriate.

How did you hear about us

How did you find out about our PrEP program?

I am filling out this form because:

If you have questions about PrEP, insurance, or cost, please share them below. A PrEP Navigator will reach out to support you.

Basic Info

Language:

Preferred name:

Name:

First NameMiddle NameLast Name

Date of Birth:

Address:

Street Address

Street Address Line 2

CityState

Zip Code

Phone:

Please enter a valid phone number.Format: (000) 000-0000.

Email:

example@example.com

Preferred contact method:

Identity

Sex: (Assigned at birth)

Gender:

Identify as:

Race(s):

Hispanic/Latino:

Insurance Information

Employed:

Health Insurance:

If insured:

Upload card (front/back)

Insurance will be reviewed by our team before scheduling your appointment.

Front upload of card

Back upload of card

Front of card

Back of card

Sliding Fee (Only if Uninsured)

If you do not have insurance, this information helps us determine eligibility for reduced-cost services.

What is your estimated total annual income (before taxes)?

Example: If you earn about $2,000 per month, your annual income would be $24,000($2,000 × 12 months).

How many people are in your household that you financially support?(Include yourself. A dependent can be a child, partner, or relative you help support.)

ID Upload

Government-issued photo ID upload

Consent

Participant Agreement

I understand I must complete required lab tests
I will attend my provider follow-up visit
I will take PrEP as prescribed
I will attend injection visits if applicable

Signature

Authorization

I allow SAAF staff to contact me regarding PrEP care
I authorize assistance with PrEP enrollment and medication access if needed

Signature

Your Next Step is Confidence