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Medical Information Form

Legal First Name *

Legal Last Name*

Date of Birth *

Cell Phone Number *

Email Address *

Mailing Address * (Enter the address where you would like to receive your prescription and/or lab test kit if selected)

City *

State*

Zip Code *

Insurance Information

Do you have prescription insurance? *

Prescription Insurance Card ID

Prescription Insurance Pcn

Prescription Insurance RxBin

Prescription Insurance RxGroup

Please identify all your current medical conditions

Please list all your current medications including dosages

Please list all of your known allergies

What is your height in feet and inches?

What is your weight in pounds?

Have you ever been diagnosed with HIV?

When did you first consider PrEP?

What was your sex assigned at birth?

Are you currently pregnant, breastfeeding or planning to become pregnant?

Do any of the following apply to you? (select all that apply): I have condomless intercourse with a partner of unknown HIV statusI have condomless intercourse with a partner who is HIV positiveI am a man who has sex with men (MSM)I have multiple sexual partnersI have a recent diagnosis of a sexually transmitted infection (e.g., gonorrhea, chlamydia, syphilis)I engage in injection drug useMy partner participates in injection drug useI have another risk factor that I’m concerned aboutNone of these apply to me

Please provide further details about your other risk factors

Have you ever taken or are you currently on PrEP therapy?

Which PrEP regimen(s) have you taken?

Have you ever experienced any side effects or complications while on PrEP?

Please provide further information including which medication caused the reaction, the severity, and what symptoms you experienced

Do you have a history of kidney disease or reduced kidney function?

Tell us more about this diagnosis and your most recent labs such as your creatinine or eGFR

Have you ever been diagnosed with hepatitis B or C?

Please provide further information including dates of treatment and what medications you received

Do you have a history of bone density issues or osteoporosis?

Truvada (TDF/FTC) has been associated with small decreases in bone mineral density, which may be particularly relevant if you have osteoporosis, whereas Descovy (TAF/FTC) has been shown in clinical studies to cause minimal changes in bone density. It is important that you continue to participate in weight bearing activities and follow closely with your doctor to monitor your bone density. Knowing this small but potential risk, would you like to continue?

Consent (Taking Your PrEP Medication & Supporting Your Health):

Are you willing and able to commit to regular laboratory monitoring (e.g., HIV testing every 3 months, kidney function tests, etc.)?

What other information or questions do you have for the doctor?

Consent (Truthfulness):

Please attest to the following confirming that all information you have provided to us is true and complete.

I verify that I am the patient and that I have answered the questions asked in this intake form. I confirm that I have reviewed and understood all the questions asked of me. I attest that the answers and information I have provided in this questionnaire is true and complete to the best of my knowledge. I understand that it is critical to my health to share complete health information with my doctor. I will not hold the doctor or affiliated medical practice responsible for any oversights or omissions, whether intentional or not, in the information that I provided.

Consent (HIV Pre-Exposure Prophylaxis (PrEP) with Truvada® or Descovy® & Supporting Your Health):

Acknowledgment and Consent:
I have read and understand the information above regarding the use of Truvada® or Descovy® for HIV pre-exposure prophylaxis. I/We consent to medical treatment and diagnostic procedures by Sagebrush Health, its affiliates, and Beluga Health. I also authorize the release of information needed to process claims, labs, and prescriptions. I understand the potential benefits, risks, and requirements for monitoring, and I agree to adhere to the follow-up schedule Find more details under medication information

PrEP is a daily pill regimen that is 99% effective at preventing HIV. PrEP is covered by most insurance companies and we offer patient assistance if needed.

Pharmacy:

1 Chestnut Street Suite
200 Nashua, NH 03060

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