Pre-Exposure Prophylaxis (PrEP) Self-screening Form
(Confidential – Protected Health Information)
Patient Background and Medical History
These questions will help the pharmacy team determine if PrEP is right for you.
In the past 6 months, have you had a sexual partner who is a
Please bring your enrollment card to your visit.
THE ABOVE INFORMATION IS TRUE TO THE BEST OF MY KNOWLEDGE. I AUTHORIZE MY INSURANCE BENEFITS TO BE PAID DIRECTLY TO THE PHYSICIAN. I ALSO AUTHORIZE SAGEBRUSH HEALTHCARE OR MY INSURANCE COMPANY TO RELEASE ANY INFORMATION REQUIRED TO PROCESS MY CLAIMS.