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Medical Information Form to Get Your PrEP Prescription.

We’d love to make this form shorter, but everything we ask is required to provide your PrEP!

    DTC Consent for Treatment

    PATIENT CONSENT FOR MEDICAL TREATMENT

    I/WE VOLUNTARILY CONSENT TO MEDICAL TREATMENT AND DIAGNOSTIC PROCEDURES PROVIDED BY SAGEBRUSH HEALTH AND ITS ASSOCIATED PHYSICIANS, CLINICIANS, AND OTHER PERSONNEL. I/WE CONSENT TO THE TESTING FOR INFECTIOUS DISEASE, SUCH AS, BUT NOT LIMITED TO SYPHILIS, HIV, HEPATITIS, AND ANYTHING ELSE DEEMED ADVISABLE BY MY PHYSICIAN. I/WE AM/ARE AWARE THAT THE PRACTICE OF MEDICATION IS NOT AN EXACT SCIENCE AND I/WE ACKNOWLEDGE THAT NO GUARANTEES HAVE BEEN MADE AS TO THE RESULTS OF TREATMENTS OR EXAMINATIONS.

    PATIENT CONSENT FOR TELEHEALTH VISIT

    Telehealth is the delivery of health care services using interactive audio and video technology, where the patient and the Health Professional are not in the same physical location. During your telehealth consultation with a Health Professional, details of your health history and personal health information may be discussed with you and video, audio, and/or photo recordings may be taken. The telehealth services you receive from the Health Professionals are not intended to replace your relationship with your primary care physician or other physicians you may consult. You should seek emergency help or follow-up care when recommended by a Health Professional or when otherwise needed and continue to consult with your primary care physician and other healthcare professionals as recommended. With any health service, there are potential risks associated with the use of telehealth. These risks include, but may not be limited to:

    • In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate health care decision making by the Health Professional;
    • Delays in evaluation or treatment could occur due to failures of the electronic equipment;
    • Although the electronic systems we use will incorporate network and software security protocols to protect the privacy and security of health information, in rare instances, security protocols could fail, causing a breach of privacy of personal health information
    • A lack of access to all of your medical records (for example records that are not in your Personal Health Record provided) may result in adverse drug interactions or allergic reactions or other judgment errors.

    You understand that you may expect the anticipated benefits from the use of telehealth in your care, but that no results can be guaranteed or assured. Your chosen Health Professional may determine that use of the Telemedicine Portal is not appropriate for some or all of your treatment needs.

    THE ABOVE INFORMATION IS TRUE TO THE BEST OF MY KNOWLEDGE. I ALSO AUTHORIZE SAGEBRUSH HEALTHCARE OR MY INSURANCE COMPANY TO RELEASE ANY INFORMATION REQUIRED TO PROCESS MY CLAIMS.

    Pre-Exposure Prophylaxis (PrEP) Self-screening Form

    Pre-Exposure Prophylaxis (PrEP) Self-screening Form

    (Confidential – Protected Health Information)

    Front of Image Needed
    Back of Image Needed
    Image Needed
    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.

    Medical History

    SOCIAL HISTORY INFORMATION

    LIST ALL ALLERGIES

    ×

    PLEASE LIST ALL CURRENT MEDICATIONS *

    Name of Medication

    Strength

    Frequency

    SURGICAL HISTORY *

    Year

    Surgery/Procedure

    Location

    FAMILY MEDICAL HISTORY

    Symptoms and History

    /* */