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Sexual health – PrEP online request form

Your information

If you would like to find out what happens to personal information held about you, please read the your personal information section on our privacy policy page for more information.

Sexual Health - PrEP online request form

We are making it easier for people taking PrEP to continue to access this. Should you choose to continue, you will be asked to complete a few questions online. A clinician will then review your completed self-assessment and we will then contact you with advice on what to do next. 

Please note that we will be unable to review any symptoms or treat any infections during this type of PrEP appointment. If you have symptoms, need treatment for an infection, are due a vaccination, please call 0300 7900 0245 or 0300 123 1678.

This option is unsuitable for people who get PrEP via commercial trials or who would like to start PrEP (for example, if you have never had PrEP before, or if you have had a break from PrEP).

Consent

Demographics

Name(Required)
Date of birth(Required)
This field is hidden when viewing the form
OLD INACTIVE Gender

Medical history

Do you have any medical conditions or diagnoses (including any kidney problems)?(Required)
Do you take any regular medications (including any herbal remedies, over-the-counter medication and vitamins or supplements or contraception)?(Required)
Select date DD slash MM slash YYYY
Do you smoke or vape?
How often do you have a drink containing alcohol?
Have you used any recreational or party drugs in the last three months?

Sexual Health assessment

How many sexual partners have you had in the last three months?(Required)
Are you currently experiencing any difficulties with sexual performance or satisfaction?(Required)

Risk assessment history

Are you currently or have you ever experienced any of the below?

PrEP risk and exposure

Do you have any questions, issues or side effects related to your PrEP medication?(Required)
Have you missed any pills in the last three months?(Required)
Approximate number of days of PrEP remaining?(Required)
DD slash MM slash YYYY
Select date DD slash MM slash YYYY

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