PrEP & PEP Intake

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PrEP & PEP Intake

ProTecht Private, Encrypted | Usually takes 3–5 minutes | Complete this confidential intake to help the Check Coast care team understand your needs and determine the appropriate next steps for PrEP or PEP care. Your information will be reviewed by a licensed clinician.
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Email

Confirmation Emailexample@example.com
What do you need today?
original_intent
branch_path
pep_hiv_status_at_intake
pharmacy_assigned
payment_status

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EXPOSURE

PEP is time-sensitive. The following questions help us understand when a possible exposure occurred so our care team can determine the appropriate next steps.
When did the possible exposure happen?
PEP generally must be started within 72 hours after a possible exposure. Because more than 72 hours have passed, a clinician should review your situation and discuss testing and prevention options with you. Continuing this form does not guarantee that PrEP or any other medication will be prescribed.

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YOUR INFORMATION

Please provide your current information so our care team can safely coordinate your care and contact you according to your communication preferences.
Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Are you of 18 years or older?
Because you are under 18, we need to connect you directly with one of our trained team members so we can explain the services available to you and how privacy, consent, and payment may work.

Call or text 941-205-9619. If this may place you at risk or someone else can access your phone, call when you are in a safe and private place.
minor_status
Mobile Number
Please enter a valid phone number.Format: (000) 000-0000.
How may we identify ourselves if we call or text?
May we leave a voicemail or send a secure text to the above mobile number?

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QUICK HEALTH CHECK

The following questions help your clinician understand your health history and determine which care and treatment options may be appropriate for you. Please answer as accurately as possible.
Do you have any known medication allergies?
List your medication allergies and reactions.
Please list any medications you currently take, including prescription medications, over-the-counter medications, vitamins, and supplements. If none, enter "None".
Have you ever taken PrEP?
If yes, what PrEP medication did you take, and approximately when did you start/stop taking it?
Have you ever taken PEP?
If yes, what PEP medication did you take, and approximately when?

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NEXT STEPS
Thank you for sharing this information. PEP and PrEP are not treatments for someone who has HIV, but our team can help connect you with appropriate HIV care and answer questions about prevention for partners.

A team member will contact you privately using the communication preferences you selected.

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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 PREFERENCE

If PrEP is prescribed, we'll use the information below to coordinate your prescription with the pharmacy or delivery option you select.
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 PREFERENCE

If PEP is prescribed, our care team will coordinate your prescription as quickly as possible. Please provide the information below to help us arrange pharmacy pickup or delivery.
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 review the following acknowledgments carefully before providing your consent and signature.
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

First NameMiddle NameLast NameSuffix
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hour MinutesAM/PM Option
Should be Empty:

PrEP & PEP Intake

EXPOSURE

YOUR INFORMATION

QUICK HEALTH CHECK

TESTING

NEXT STEPS

PHARMACY PREFERENCE

PHARMACY PREFERENCE

COST & COVERAGE

CONSENT & SIGNATURE