Demographics

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Demographics

Email *

Name *

Date of Birth *

YYYY

Social Security Number

Address *

City, State and ZIP

Phone number *

Sex

Male

Female

Other:

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Marital Status

Race

Primary Insurance Name, ID number and group number *If you do not have insurance write uninsured *

Have you ever been tested for HIV? If so when was your most recent test? *

Have you ever had a sexually transmitted infection? If yes, name the infection(s).

List any medical problems that other doctors have diagnosed *

Surgeries and year completed *

Medications including over-the-counter drugs *

Allergies to medications and reaction you had *

Family Health History *

Policy

PrEPonDemand is committed to protecting the privacy of your health information. We posted in the office and have available for you upon request our privacy policy, also known as, Notice of Privacy Practices (NPP). Our policy describes how we safeguard, and when and with whom we may share our/your medical information. This policy complies with Federal regulations. Within the policy are procedures for restricting release and modifying information. I understand that services rendered to me by PrEPonDemand, are my financial responsibility and that I will be fully responsible for any outstanding balance on my account. This consent form authorizes PrEPonDemand to obtain and review my prescription history. Detailed prescription history provides your physician with information about medications being prescribed by other providers involved in your medical care. This information will improve the accuracy of our medication list in your medical chart and decrease any adverse drug reactions or inaccurate medication information such as medication names or dosages. By agreeing to this consent form PrEPonDemand can request and use your prescription medication history from other healthcare providers, pharmacies, and benefit payors (such as your insurance company) for treatment purposes. Understanding all of the above, I hereby provide informed consent PrEPonDemand to request, view, and use my external prescription history for treatment purposes.

Consent To the best of my knowledge, the information on this form is accurate; and I will advise PrEPonDemand of any material changes. I also acknowledge i am able to request a copy of the HIPPA Notice of Privacy Practices. By signing this you are acknowledging that you understand PrEPonDemand's policy. By typing my name below I agree to all of the above. *

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