Reasearch New Leads Form

1

What is Your Full Name* This field is required.

First Name

Last Name

2

What is your Best Email?* This field is required.

example@example.com

3

What is your Phone Number* This field is required.

Please enter a valid phone number.

4

Age (Must be 18+)* This field is required.

18 and older

Under 18

5

Have you been diagnosed with HIV?* This field is required.

YES

NO

6

Are you currently taking HIV medication?* This field is required.

YES

NO

7

What HIV medication are you currently taking?* This field is required.

Biktarvy

Triumeq

Dovato

Other

8

Have you been on HIV medication for at least 6 months?* This field is required.

YES

NO

9

Would you be open to a long acting HIV treatment given as injections instead of daily pills?* This field is required.

YES

NO

10

Have you been told your viral load is undetectable?* This field is required.

YES

NO

Not sure

11

How long have you been off HIV treatment?* This field is required.

I’ve never been on treatment

Less than 12 weeks

12 weeks or More

Not sure

12

Do you currently have active Hepatitis C for at least 6 months (not cleared)?* This field is required.

Yes

No

Unsure

13

Are you able to bring medical records and lab results from the last 6 months to your screening visit?* This field is required.We require recent medical records (within 6 months) to confirm eligibility.

YESNO

14

Please share any medical conditions you’ve been diagnosed with.* This field is required.(This helps us match you with future clinical trials.)

15

Are you able to bring in medical records and lab results from the last 6 months?* This field is required.To be eligible, you’ll need to bring a copy of your medical records and lab results to your first visit.

YESNO

16

What current HIV medication are you taking* This field is required.

17

Can you commit to answering our call in the next 48 hours?* This field is required.Reply YES or NO, and share the best time(s) to reach you (Mon–Fri, 8 AM–5 PM). Feel free to mention anything we should know, like your schedule or availability.