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PrEP Referral Form Faxed prescriptions will only be accepted from an authorized prescriber. Prescribers are reminded patients may choose any pharmacy of their choice1.Patient InformationPatient Name:
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How to fill out prep referral form
How to fill out prep referral form
01
Obtain the prep referral form from a healthcare provider or clinic.
02
Fill in your personal information such as name, date of birth, and contact information.
03
Provide details about your sexual activity and potential risk factors for HIV.
04
Answer any additional questions about your medical history and current health status.
05
Sign and date the form to confirm that the information provided is accurate.
06
Submit the completed form to the healthcare provider or clinic for review and processing.
Who needs prep referral form?
01
Individuals who are at risk for HIV infection and are interested in starting pre-exposure prophylaxis (PrEP) treatment.
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What is prep referral form?
The prep referral form is a document used to refer individuals to pre-exposure prophylaxis (PrEP) services for HIV prevention.
Who is required to file prep referral form?
Healthcare providers and organizations working with at-risk populations are required to file prep referral forms.
How to fill out prep referral form?
To fill out a prep referral form, healthcare providers will need to gather information on the individual's medical history, risk factors, and contact information.
What is the purpose of prep referral form?
The purpose of the prep referral form is to connect individuals at risk for HIV with PrEP services to prevent infection.
What information must be reported on prep referral form?
The prep referral form must include the individual's demographic information, risk factors for HIV, medical history, and contact information.
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