Check Coast - ED Intake Form

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ED Intake Form`

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Complete this confidential intake to help the Check Coast care team understand your symptoms, health history, and treatment needs.

A licensed clinician will review your information to determine appropriate next steps. Completing this form does not guarantee that medication will be prescribed.
Email

Confirmation Emailexample@example.com
What are you looking for today?
original_intent
branch_path
pep_hiv_status_at_intake
pharmacy_assigned
payment_status
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Before PrEP is prescribed, your clinician must confirm that the required HIV testing and other clinical requirements are complete. Choose the testing option you prefer. A team member will confirm availability, location, timing, and any cost before the visit.
Which option do you prefer?

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Pharmacy Preferences
If PrEP is prescribed, where would you prefer the prescription to be sent?
Please provide your current address. This information is required to help us identify an appropriate local pharmacy or coordinate discreet medication delivery, if selected.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

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PEP is time-sensitive. A clinician will review your information promptly and determine the appropriate next step. Baseline free HIV testing is part of PEP care, but testing should not create an unnecessary delay when PEP is clinically indicated.
If PEP is prescribed, the prescription will be sent to the approved 24-hour partner pharmacy shown below. The care team will confirm the prescription and pickup instructions.
Pharmacy Preferences
Which of the following would you prefer the prescription to be sent?
If mailed, please provide the address you would like to receive your discreet shipment?
Address

Street Address

Street Address Line 2

CityState

Zip Code

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COST & COVERAGE

We'll review any coverage, cost, and payment options that may apply to your care before services are provided or medication is prescribed.
How would you like us to review medication coverage?

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CONSENT & SIGNATURE

Please read and sign the following:
Notice of Privacy Practices

Please review our Notice of Privacy Practices before providing your acknowledgment below.
I acknowledge that I received or had the opportunity to review the Notice of Privacy Practices.
I consent to receive care through telehealth. I understand the potential benefits, risks, and limitations; that an in-person evaluation may be recommended; and that I may withdraw consent as allowed by law without losing the right to future care.
I understand that this service is not for emergencies. If I believe I am experiencing a medical emergency, I will call 911 or go to the nearest emergency department.
I understand that PEP is time-sensitive and generally must be started within 72 hours after a possible exposure. Submission of this form is not a prescription or guarantee of treatment.
I understand that HIV testing and other laboratory testing may be required as part of my care. PrEP will not be started unless the prescribing clinician confirms that the clinical requirements are met.
I consent to evaluation and treatment and authorize One Check Away, Inc. and its Check Coast Clinic to disclose information to healthcare providers, laboratories, pharmacies, health plans, and other persons or entities as permitted by law for treatment, payment, and healthcare operations.
Full Legal Name

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Signature
Date

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2 digit month, 2 digit day, 4 digit yearDate
Hour MinutesAM/PM Option
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ED Intake Form`

Your Information

ED Symptoms & History

Health & Safety

Medications & Treatment Safety