San Antonio AIDS Foundation PrEP Referral Form

San Antonio AIDS Foundation PrEP Program Referral Form

Please complete the form and a PrEP Nevigator will contact you.
This form is not for testing appointments. If interested in HIV/STI testing please visit our website for location and hours.

https://sanantonioaids.org/services/testing/
Attention:

The Care Clinic located inside the San Antonio AIDS Foundation will be charging a one-time fee of $100 to start PrEP. This fee will only be charged for clients who are uninsured.
Please read before continuning with the referral:

PrEP program
- PrEP lab appointments are only available Monday through Friday from 8:30 a.m. to 3:30 p.m.
- PrEP provider appointments days are limited. PrEP provider appointments are scheduled Monday, Tuesdays PM, Wednesdays and Friday AM. The clinic is closed on weekends and closed for lunch from 12:00 pm to 1:0O pm.
- There are two PrEP apppointments every 3 months. After completing the PrEP labs, a PrEP provider visit take place at a different date (Usually in 1 -3 weeks.)
- PrEP medication will be prescribed at the PrEP provider appointment.
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.
How did you hear about SAAF's PrEP program:*

During my testing session at SAAF (Please select tester below)The Care Clinic (Located inside SAAF)During an outreach eventAnother orginizationSocial mediaWord of mouthOther
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?
Health insurance front
Please provide a clear picture or upload your Health Insurance

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

Cancelof
Health insurance Upload

Cancelof
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 ACKNOWLEDGE YOUR COMMITMENT TO YOURSELF AND TO THE PREP PROGRAM AS FOLLOWS.

1) Comply with laboratory analysis every 3 months.

2) Meet with the PrEP provider 1 - 3 weeks after the lab test is complete.

3) Take the PrEP medication daily as prescribed.

4) Please be advised that there is a one-time fee of $100 applicable to uninsured patients.
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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San Antonio AIDS Foundation PrEP Program Referral Form

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