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First Name

Last Name

Phone Number

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Local Partners

We partner with local non-profit organizations that can help pay for your medical expenses.

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Personal Info

Sex Assigned at Birth

Gender

Date of birth

Choose calendar date or enter mm/dd/yyyy

Height

Weight (lbs)

Preferred Language

Race

Ethnicity

Sexuality

Pronouns

Nickname

PrEP Conditions

Have you ever been diagnosed with HIV?

Do you already have a current PrEP prescription?

Have you ever been diagnosed with syphilis?

Insurance

Insurance is not needed to participate in this program. But the pharmacy will need to know if Insurance exists.

Do you have insurance?


(Last 4) Social Security #

SSN is used for patient assistance programs, information is not shared with any federal agency. ENTER 1111 IF YOU DO NOT HAVE A SOCIAL SECURITY NUMBER.

Gilead Patient Assistance

Lacking Insurance coverage or have been denied coverage by your insurance plan? No problem!

Our team can help by enrolling you into Gilead Advancing Access® or Co-Pay Program, which will likely help cover the cost of your medication. Please note, in order to qualify for PrEP at no cost, you must not earn more than $62,450 annually. This information is confidential and is only shared with the drug maker Gilead and no credit checks are performed. If you make over the amount, we have a few other solutions we can enroll you into to ensure your medications is affordable. The additional information below will help our team do all the work for you!

Number of people in household?

Annual Income

Are you eligibile for VA benefits?

Are you eligibile for Medicaid?

Address

Address

Apartment, suite, floor

City

State

Zip

 

Local Partners

(You are looking at this page again because you changed the zip code you entered at the beginning)

We partner with local non-profit organizations that can help pay for your medical expenses.

(Searching for a local partner...)

 

Schedule Your Appointment

Schedule your telehealth appointment with our physician by clicking on a date and then time. If no dates are available or you wish to do this later, click skip.

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Choose Date

Choose Time

  

Sign and Submit

Take a look at your info below, feel free to correct anything by using the previous button to return to the correct prompt. To submit your information, click finish.

Name

Email Address

Phone

Location

Date of Birth

Has PrEP?

Is Insured?

Signature

Use your mouse or finger to sign the area below.

Thanks For Enrolling!

 

Look out for an email regarding next steps and your appointment with a Q Care+
provider. If you did not schedule an appointment we will be in contact or you may
contact us at hello@qcareplus.com

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We look forward to bringing your PrEP!

 

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Presciption

For my current PrEP prescription, I can:

Health Questionnaire

Have you been exposed to HIV+ blood or semen in the last 72 hours?

Who are you normally having sex with? (check all that apply)

How many sex partners have you had in the last 6 months?

What type of sex do you normally have?(check all that apply)

Have you had sex without a condom in the last 6 months?

Have any of your sex partners been HIV+ in the last 6 months?

Have you been diagnosed with any of the following in the last 6 months?

Have you ever been diagnosed with syphilis?

Have you ever been diagnosed with any of the following? (check all that apply)