Free PrEP – OHIV.org

Consent for Service*

By selecting "I Agree", you agree to have the information on this form shared with and to be contacted by a local PrEP Health Navigator.

First Name*

Last Name*

Pronouns*

Please select how you would like a PrEP Health navigator to address you when they reach out:

Prounouns Cont.

If you selected "other" to the above question, please type your preferred pronouns:

What is your race?

Check all that apply.

What is your ethnicity?

Another Hispanic, Latino/a, or Spanish Origin
Cuban
Mexican, Mexican American, or Chicano/a
Multiple Hispanic, Latino/a, or Spanish Origins
Non-Hispanic or Latino/a
Patient Refused
Puerto Rican
Unknown

Check all that apply.

Are you an employee of Equitas Health, the Ohio Department of Health, or does an ODH grant fund your work?

Yes
No

Zip Code*

Please type your zip code:

Primary Phone*

If you do not have a phone number please input: 555-555-5555

Secondary Phone

(Optional)

Voicemail*

May we leave you a voicemail:

Email*

Enter Email Confirm Email

Best Way To Reach You?*

How should we get in touch?

Insurance Status*

Please choose what kind of insurance you do or do not have currently:

In which Ohio county do you live?*

Please select from the drop down list

What is your income?*

How much money do you make every year?

What gender were you assigned at the time of your birth?*

What is your gender today?*

Date of Birth*

Referral Source*

How did you find out about this program?

If you selected "Healthcare Organization" please write which agency below

If you selected "Other" to the above question, please describe how your heard about the PAPI Program:

What was the community event?

What social media platform did you learn about PAPI from?

Ex: Twitter, Facebook, Instagram, Grindr, etc.

Tele-Prep

(Skip if not applicable) Do you have a tele-prep appointment scheduled?

Accommodations

Do you require any accommodations such as a Translator, ASL Interpreter, or other assistance to work with a navigator?

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