Request a Callback from Legacy Community Health
By entering my information here I am requesting that the Legacy Community Health contact me about scheduling an appointment to discuss getting on PrEP (Pre-Exposure Prophylaxis) or PEP (Post-Exposure Prophylaxis; after sex), HIV Testing, STI Testing or Pregnancy Testing.
Al ingresar mi información aqui, estoy solicitando que Legacy Community Health me contacte para programar una cita y hablar acerca de inscribirme en PrEP o PEP, pruebas de VIH, pruebas de infecciones de transmisión sexual, o pruebas de embarazo.
* Required
Name / Nombre
*
Your answer
Date of Birth / Fecha de nacimiento
*
MM
/
DD
/
YYYY
Phone number / Número de teléfono
*
Your answer
Email / Correo electrόnico
Your answer
Gender (At birth): What sex were you assigned at birth? On your original birth certificate: - Cuál es el género que le asignaron al nacer (que esta en su certificado de nacimiento)
Male
Female
Current Gender Identity: What is your current gender identity: - Cuál es su identidad de género?
*
Male
Female
Transgender Male/Female to Male
Transgender Female/Male to Female
Non-Binary
Other
Choose not to disclose
Required
Which clinic(s) is most convenient? - Cuáles clinicas le quedan más cerca?
*
Legacy Central Beaumont Clinic
Legacy Lyons Clinic
Legacy Mapleridge Clinic
Legacy Midtown Main Clinic
Legacy Montrose Clinic
Legacy Northline Clinic
Legacy San Jacinto Clinic
Legacy Santa Clara Clinic
Legacy Southwest Clinic
Required
Referral Source
Your answer
For More Information
For more information about Legacy Community Health Pharmacy, PrEP, PEP and other services, please visit our website:
www.LegacyCommunityHealth.org/Pharmacy
www.LegacyCommunityHealth.org/GetTested
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