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(PrEP) Self-screening Form

Pre-Exposure Prophylaxis (PrEP) Self-screening FormPlease note: completion of this form does not guarantee that a prescription will be written. The decision to prescribe PrEP medication is at the sole discretion of the healthcare provider, based on their professional judgment and evaluation of your individual medical needs and circumstances. Please make sure to have your government-issued ID and your insurance card ready.

Eligibility Screening

Answer a few questions to make sure that you're a good candidate for our FREE PrEP program! This form takes ~2 minutes to complete.

Patient Consent For Telehealth Visit

Telehealth is the delivery of health care services using interactive audio and video technology, where the patient and the Health Professional are not in the same physical location. During your telehealth consultation with a Health Professional, details of your health history and personal health information may be discussed with you and video, audio, and/or photo recordings may be taken. The telehealth services you receive from the Health Professionals are not intended to replace your relationship with your primary care physician or other physicians you may consult. You should seek emergency help or follow-up care when recommended by a Health Professional or when otherwise needed and continue to consult with your primary care physician and other healthcare professionals as recommended. With any health service, there are potential risks associated with the use of telehealth. These risks include, but may not be limited to:
Telehealth is the delivery of health care services using interactive audio and video technology, where the patient and the Health Professional are not in the same physical location. During your telehealth consultation with a Health Professional, details of your health history and personal health information may be discussed with you and video, audio, and/or photo recordings may be taken. The telehealth services you receive from the Health Professionals are not intended to replace your relationship with your primary care physician or other physicians you may consult. You should seek emergency help or follow-up care when recommended by a Health Professional or when otherwise needed and continue to consult with your primary care physician and other healthcare professionals as recommended. With any health service, there are potential risks associated with the use of telehealth. These risks include, but may not be limited to:
- In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate health care decision making by the Health Professional;
- Delays in evaluation or treatment could occur due to failures of the electronic equipment;
- Although the electronic systems we use will incorporate network and software security protocols to protect the privacy and security of health information, in rare instances, security protocols could fail, causing a breach of privacy of personal health information
- A lack of access to all of your medical records (for example records that are not in your Personal Health Record provided) may result in adverse drug interactions or allergic reactions or other judgment errors.
You understand that you may expect the anticipated benefits from the use of telehealth in your care, but that no results can be guaranteed or assured. Your chosen Health Professional may determine that use of the Telemedicine Portal is not appropriate for some or all of your treatment needs.
Signature*

Clear
The above information is true to the best of my knowledge. I also authorize Curaa Health or my insurance company to release any information required to process my claims.

Yes

Consent for Treatment

Patient Consent For Medical Treatment
I/we voluntarily consent to medical treatment and diagnostic procedures provided by sagebrush health and its associated physicians, clinicians, and other personnel. I/we consent to the testing for infectious disease, such as, but not limited to syphilis, hiv, hepatitis, and testing for drugs if deemed advisable by my physician. I/we am/are aware that the practice of medication and surgery is not an exact science and I/we acknowledge that no guarantees have been made as to the results of treatments or examinations.
Signature*

Clear

Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com

Assigned sex at birth*

MaleFemale

Language*
If ‘Other’, Please Specify Your language

Date of Birth*

MonthDayYear
Date

Address
Street Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Patient demographic*
Ethnicity*
Race*
If other, please specify your Race *
Weight (in lbs)*
Height*
Feet*
Inches*

Do You Currently Have Health Insurance?*

YesNo

Do you have Medicaid or Kaiser? *

YesNo

Please upload a copy of the front & back of your insurance card *
Front Image*
File Upload

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Back Image*
File Upload

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Please upload an image of your State issued Photo ID (with photo and date of birth visible) *
File Upload

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Last step! After you submit your Intake Form, a team member will reach out in 24 hours to schedule you for an appointment with our provider.
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(PrEP) Self-screening Form

Eligibility Screening

Patient Consent For Telehealth Visit

Consent for Treatment

Address

Patient demographic*

Height*

Please upload a copy of the front & back of your insurance card *

Front Image*

Back Image*

Please upload an image of your State issued Photo ID (with photo and date of birth visible) *

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