SAAF PrEP Referral Form (Testing)

Your Next Step is Confidence!

Please complete the form, and a PrEP Navigator will contact you. Please allow 1–2 business days for a PrEP Navigator to reach out.
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.
What You Need to Know Before Starting PrEP With Us
PrEP Program Information

To stay on PrEP, you’ll need regular check-ins with our clinic team. This includes:
- Routine labs to complete all required testing.
- A provider visit (usually scheduled after your lab results).
Oral PrEP

Your PrEP medication will be prescribed during your provider visit.

Injectable PrEP

1. A provider visit to talk about which PrEP injection is right for you.

2. A seperate appointment to receive the injection.

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 PrEP is for people who are HIV-negative and want to take control of their sexual health.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 injections a year.
We offer Doxy PEP, which can be discussed during your appointment with the provider.
How Did You Hear About Us?
How did you hear about SAAF's PrEP program:*

During my testing session at SAAFSocial mediaWord of mouthOtherDuring an outreach event
I am filling out this form because:*

I am ready to start PrEP.I am interested in receiving more information regarding PrEP.
We’re here to help.If you have questions about PrEP, insurance, or cost, please share them below. A PrEP Navigator will reach out to support you.
Demographic Information
Preferred language:*

EnglishSpanishOther
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
Tell Us About Yourself
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
Employment & Health Insurance Information
Employed:*

YesNo
Health Insurance:*

YesNo
Please upload a clear photo of your health insurance card.

Your insurance must be verified before we can schedule your appointment.
Health insurance front upload

Cancelof
Health insurance back upload

Cancelof
Upload Photo of Insurance Card (Front & Back)
Health insurance front
Health insurance back
Sliding Fee Eligibility (Uninsured Only)
If you do not have health insurance, please answer the questions below.
Your answers help us determine your sliding fee for lab work and provider visits. All information is confidential.
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.)
Upload Government-Issued Photo ID
Please provide a clear picture of your Government-issued photo ID (driver’s license, state ID, passport)
Identification
Program Agreement, Consent & Authorization
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.
Signature*

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