PrEP Interest Form

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PrEP Interest Form

PrEP (Pre-Exposure Prophylaxis) is a medical program that offers daily medication to prevent HIV among people without HIV. If you are interested in HIV services for a person who is positive, please call 240-313-3331.

Please fill this confidential form out to the best of your ability and then click the submit button. A patient navigator will reach out to you with the phone number you provided below.

Please type your first and last name(s): *

Please type your preferred phone number: *

Please type your email:

What is your date of birth? *

YYYY

Choose the gender you identify with:

Male

Female

Transgender

Non-binary

Prefer not to say.

Other:

Choose your race:

Black or African-American

American Indian or Alaskan Native

Asian

Native Hawaiian and Pacific Islander

White

Other:

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Choose your ethnicity:

Hispanic

Not Hispanic

Prefer not to say.

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How did you hear about our PrEP Program?

HIV Testing

Allegany County Heath Department Family Planning Clinic

Allegany County Heath Department STI Clinic

Your doctor or urgent care

Friend

PrEP ad or our website

Other:

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Submit

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