Request Form for PrEP Medication

Please complete the following form if you would like to continue to get your pre-exposure prophylaxis (PrEP) from SHiP.

PrEP is medication that you can use to prevent HIV infection if you are having high-risk sex, such as anal sex without a condom. You can take it daily or as and when you need it.

However, it cannot protect you against other sexually transmitted infections (STIs) such as chlamydia, gonorrhoea and syphilis. Therefore, it is recommended that you have an STI screen every 3 months if you are taking PrEP, regardless of whether you have symptoms or not. Although PrEP is usually well tolerated, it can cause kidney issues, but we will regularly monitor your kidney function. PrEP may also cause a reduction in bone density, but as this is a process that occurs very slowly, we do not routinely monitor for this.

If you decide that you no longer want to take PrEP, please continue taking it for at least 48 hours after any high-risk sex before stopping. If you are concerned that you have not taken the PrEP correctly because you have missed doses, please consider taking post-exposure prophylaxis (PEP). PEP needs to be taken within 72 hours of high-risk sex and is available 24 hours a day, 7 days a week from either SHiP or the Emergency Department.

Your Details

1.       Are you taking PrEP daily or on demand or in another way?

Reminder on how to take PrEP on demand

If you know that you might have high-risk sex (eg anal sex without a condom) 24 hours in advance:

• take 2 pills 2 – 24 hours before sex
• take 1 pill 24 hours later
• take 1 more pill 24 hours after that

If you’re having high-risk sex for an extended period of time, perhaps over a few days or a weekend, continue to take a pill every 24 hours until you have 2 sex-free days.

If you said you take PrEP in another way, briefly explain how you use PrEP

2.  Have you missed any doses since you were prescribed PrEP from SHiP?

If you said you have missed any doses, please state how many doses you have missed and over what time period.

3.  Has there been any change to your medical history since you were last prescribed PrEP from SHiP?

If you said there have been changes to your medical history since you were last prescribed PrEP from SHiP, please enter the details below.

4.  Has there been any change in the medication that you take since you were last prescribed PrEP from SHiP?

This includes medication that is prescribed by a doctor or nurse, purchased over the counter in the pharmacy, herbal remedies and gym supplements.

If you said there been changes in the medication that you take since you were last prescribed PrEP from SHiP, please enter the details below.

5. Have you had or do you currently have any symptoms of an STI or of an HIV seroconversion illness since you were last prescribed PrEP from SHiP?

Symptoms of an STI might include discharge or pain from the penis or the vagina, burning or stinging when you pass urine, rectal pain, rectal bleeding, rectal discharge, ulcers in the mouth or genitals, or pain while having sex.

Symptoms of an HIV seroconversion illness might include a fever, a rash and feeling generally unwell with aching joints, a sore throat and swollen glands.

6.  Who do you have sex with?

7.  Which of the following applies to you?

I have had sex without a condom in the past 6 months.

9. I have questions and would like to talk to a doctor or nurse at SHiP before getting more PrEP

Informed Consent 

 I know that missing pills or having diarrhoea and/or vomiting may prevent the PrEP from working and that I may be at risk of acquiring HIV infection. I will need to consider PEP or contact SHiP for further advice if this happens. 

 I have answered all the questions as honestly and accurately as I can. The information that I have given is my up-to-date medical history so that the SHiP team can safely assess and advise me.

 I am using this service freely on my own behalf and confirm that any treatment or advice is for my own use only.

 I fully understand the questions and information. If I am unsure about any aspect of the service, I will contact SHiP (tel: 01752 431124) before proceeding.

 I understand about how to take the PrEP, the side effects, effectiveness and what to do if I have missed doses. 

 I understand that I will inform my GP about the PrEP medication so that they can provide safe medical care.

Please indicate how you would like to receive your PrEP when it has been approved:

Please choose where you would like to pick up your PrEP when it has been approved:

Please allow 5 working days from your request, in which time you will receive a text message confirming that you can collect your supply.

Or if there are any concerns that this medication may not be suitable for you, we will send you a text message advising you that your request has been reviewed and a telephone review is required.

Please let us know your postcode.

Please allow 5 working days from your request, in which time you will receive a text message confirming that your supply has been posted to you.

Or if there are any concerns that this medication may not be suitable for you, we will send you a text message advising you that your request has been reviewed and a telephone review is required.

Please also note that if the postcode you have entered does not match the details we have for you, we not be able to post your supply.

Unfortunately we cannot process your request online. Please call SHiP on 01752 431124 to request an appointment with the sexual health team.