PrEP Referral
The information collected in this form will only be made available to the HIV Prevention Team at the Utah AIDS Foundation. With your permission, this information can be used to facilitate referral services to qualified medical providers and financial assistance programs. All information is confidential and secured by HTTPS encryption.
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Email *
Are you looking for a PrEP or an LGBTQ friendly provider referral? *
Name (First and Last) *
Age
Phone
Insured? *
Insurance Provider/Plan (The more specific you can be the better we can match you to a provider)
Do you currently have a primary care provider?
How did you learn about PrEP Referral Services? (check all that apply)
Can we follow up with you in 1 month to ask you about your experience with your healthcare provider and accessing PrEP? (You will receive the exact same referrals services whether or not you allow us to contact you in the future.) *
Can we leave a voicemail or send a text message that mentions UAF and PrEP services if we are unable to reach you on the phone?
Anything you'd like to add? If you have a primary care provider, would you recommend them and what is their name/clinic? Does your provider need education on PrEP? UAF will reach out and give them all the information they need to manage your PrEP medication.
Sex:
Ethnicity
Race:
Zip Code
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This form was created inside of Utah AIDS Foundation.