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 important step to protect your health.
A PrEP Navigator will contact you soon to help you get started and guide you through the process.

Please complete the form below to begin.
Please Read Before Continuing with the Referral

PrEP Program Information

To stay on PrEP, you’ll need regular check-ins with our clinic team. This includes:
- A lab appointment to complete required tests.
- A provider visit (usually scheduled after your lab results).
Your PrEP medication will be prescribed during your provider visit.

Clinic appointments are available on select weekdays during regular business hours.
Please note that availability may vary and the clinic is closed on weekends and holidays.
What is PrEP?
Pre-Exposure Prophylaxis (PrEP) is a safe and effective way to prevent HIV before exposure.

PrEP comes in three forms:
- Daily Pill – Taken every day and up to 99% effective in preventing HIV.
- Injectable PrEP (Every 2 Months) – An injection that provides continuous protection without needing to take a daily pill.
- Injectable PrEP (Every 6 Months) – A newer long-acting option that offers protection with just two shots per year.
PrEP is for people who are HIV-negative and want to take control of their sexual health.

We offer Doxy PEP, which can be discussed during your appointment with the provider.
Preferred language:*

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How did you hear about SAAF's PrEP program:*

During my testing session at SAAF (Please select tester below)Social mediaWord of mouthOtherDuring an outreach event
Who was your tester during your testing session?*

AnnaAnnieArnoldJazlynnJoseTray
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:*

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Sex: (Assigned at birth)*

MaleFemale
Gender:*

Cisgender MaleCisgender FemaleTrans ManTrans WomanNonbinaryOther
Identify as:*

GayStraightBisexualLesbianQueerNot listedPrefer not to say
Race(s):*

WhiteBlackAsianPacific IslanderAmerican IndianNot listed
Hispanic/Latino:*

YesNo
Employed:*

YesNo
Health Insurance:*

YesNo
Please provide a clear picture or upload your Health Insurance

Prior to scheduling, your insurance would need to be verified.
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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)
Please provide a clear picture of your Government-issued photo ID (driver’s license, state ID, passport)
Identification
Participant Agreement

By signing below, I understand and agree to the following:
- I will complete all required lab tests.
- I will attend my follow-up appointment with the PrEP provider after my lab work is done.
- I will take my PrEP medication as prescribed — whether by daily pill or injection.
- If I am on injectable PrEP, I will come to the clinic for my scheduled injection appointments to stay protected.
Signature*

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Consent and Authorization
By signing below, I give permission to be contacted about my PrEP care and management.
I also authorize my PrEP Navigator to complete PrEP assistance applications and sign related consent forms on my behalf if needed to help me access medication or services.
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Let's Get You PrEP'd and Doxy Ready!

Please provide a clear picture or upload your Health Insurance

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