First Name

Last Name



Phone Number

Preferred Language


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Local Partners

We are partnering with local organizations that can help pay for your medical expenses. Tell us where you are to help us match you with a community partner.


Apartment, suite, floor






Personal Info

Sex Assigned at Birth


Date of birth

Choose calendar date or enter mm/dd/yyyy


Weight (lbs)




Prep Conditions

Have you ever been diagnosed with HIV?

Do you already have a current PrEP prescription?

Have you ever been diagnosed with syphilis?


Do you have insurance?

(Last 4) Social Security #

SSN is used for patient assistance programs, information is not shared with any federal agency. For undocumented please enter 1111.

Lab Testing Kit

In order to take a blood sample, we'll be sending you a testing kit. Please enter the information below for the kit to be shipped to you.



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.

My Timezone

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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.


Email Address



Date of Birth

Has PrEP?

Is Insured?


Use your mouse or finger to sign the area below.


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)

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?


We will bill your insurance for the medication, and if necessary, enroll you in one of the drugmakers' patient assistance program's to cover any out-of-pocket costs. Your insurance will not be billed for the doctor consultation or the required labs.

Insurance Provider/Company

Subscriber Name

Member ID #



Group Number