CAN Online Prep – Online PrEP Application

Online PrEP Application

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Email *

Username *

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Name *

First

Last

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Date of Birth *

Preferred Language *

Pronouns

Phone *

How did you hear about our Online PrEP Program? *

Google
Facebook
Instagram
TikTok
Twitter
Grindr
Scruff
Jack’d
Other Dating site
Commercial (Radio)
Family/Friend referral
Partner/Spouse
Medical referral
Community event (outreach)
Testing in the clinic
Billboard (Outdoor Media
Other

Do you authorize CAN Community Health to contact you regarding PrEP Services? *

Do you understand that CAN Community Health will only share your health data with other health agencies as required by law? *

Accept the Terms and Conditions *

I have read and accept the Terms and Conditions *

Welcome to the CAN Community Health Online PrEP Application Page (the Online Application), a web site developed and provided for your use by CAN Community Health (“CAN”). The Online Application is provided to persons interested in PrEP enrollment to enable them to apply to receive PrEP medication and related services and facilitate communication between persons submitting PrEP applications (“Applicants”) and CAN staff regarding PrEP applications. In order to use the Online Application, you must agree to these Terms and Conditions of Use (“Terms and Conditions”) by clicking “I Accept” at the end of these Terms and Conditions.

In agreeing to these Terms and Conditions and using the Online Application and Website, you agree that any information you enter, even if you do not complete the Online Application form, may be made available to CAN, and CAN staff may use that information to contact you. In agreeing to these Terms and Conditions, you expressly agree to the access to and use of your information by CAN.
Your use of the Online Application and Website pursuant to CAN’s license expressly excludes, without limitation, any reproduction, duplication, sale, resale or other commercial use of the Online Application, making any derivative of the Online Application, the collection and use of user email addresses or other user information, including, without limitation, health information or any data extraction or data mining whatsoever.

In connection with your use of the Online Application and Website, you agree not to: (1) Restrict or inhibit any other visitor from using the Online Application, including, without limitation, by means of “hacking” or defacing any portion of the Online Application or the web site; (2) Access or attempt to access any information entered into the Online Application or owned by any other person, unless you have received express legal authorization to do so; (3) Use the Online Application for any unlawful purpose; (4) Transmit any content or information that is unlawful, fraudulent, threatening, abusive, libelous, defamatory, obscene or otherwise objectionable, or infringes the intellectual property or other rights of CAN, Licensor, or any other person; (5) Engage in spamming or flooding; (6) Transmit any software or other materials that contain any viruses, worms, Trojan horses, defects, date bombs, time bombs or other items of a destructive nature; (7) Modify, adapt, sub-license, translate, sell, reverse engineer, decompile or disassemble any portion of the Online Application or the website; (8) Remove any copyright, trademark or other proprietary rights notices contained in the Online Application or the website; (9) “Frame” or “mirror” any part of the Online Application without prior written authorization of CAN; (10) Use any robot, spider, site search/retrieval application or other manual or automatic device or process to retrieve, index, “data mine” or in any way reproduce or circumvent the navigational structure or presentation of the Online Application, the website or its contents; or (11) Harvest or collect information about applicants without their express consent. In connection with your use of the Online Application, you agree to comply with all applicable laws, rules, and regulations.

The Online Application and Website, including but not limited to its functionality and design, and all software used in the Online Application and Website, are the property of Licensor. The Online Application and Website is protected by United States and international copyright, trademark, and patent laws. The text of the Online Application is the property of CAN and is protected by United States and international copyright, trademark, and patent laws. Any rights not expressly granted herein are reserved.

CAN and Licensor are neither responsible nor liable for any injuries (including for wrongful death), direct, indirect, incidental, consequential, special, exemplary, punitive, or other damages whatsoever (including, without limitation, those resulting from lost profits, lost data, or business interruption), under any contract, negligence, strict liability or other theory, arising out of or relating in any way to the Online Application or Website, use of or inability to use the Online Application, content or information contained within or obtained from the Online Application, any hyperlinked web site, any defect in the Online Application, the Website or its contents, and/or any breach of these terms and conditions. This limitation applies (a) whether the alleged claims or damages are based on warranty, contract, tort, or any other legal theory and (b) regardless of whether or not CAN or Licensor have been advised of the possibility of such damages.

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Thank You for considering CAN Community Health for your PrEP services. Based on your responses, there was a failure to authorize CAN Community Health to contact you for PrEP services.

Please Click Here to restart your PrEP Enrollment Form

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When it comes to your health information, you have certain rights. Click Here for an explanation of your rights and some of our responsibilities to help you.

Click here to view the Initiation of Services & Consent form (PDF)

Agree to the Initiation of Services *

I agree to the Initiation of Services & Consent Forms agreement.

Signature

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By clicking “Next”, I certify that I have reviewed and signed the consents above.

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CAN Locator: Let us know your address to find a CAN Location near you.

Address *

Address Line 1

City

State

Zip Code

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Personal Information

Sex at Birth *

Gender Identity *

Sexual Orientation *

Marital Status *

Ethnicity *

Hispanic subgroup (Nationality) *

Mexican, Mexican American, Chicano/a
Puerto Rican
Cuban
Another Hispanic, Latino/a or Spanish origin

Race *

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian/Pacific Islander
White
Declined to Answer
Don’t Know

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Insurance Information

Proof of identity – Type

Upload of Identity – Front of Card *

Click or drag a file to this area to upload.

Upload of Identity – Back of Card *

Click or drag a file to this area to upload.

Last 4 Digits of Social Security number (If you have one)

Do you have health insurance? (Private Insurance, Medicaid, Medicare, VA)

Yes
No
Don’t Know

Annual Income

Number of people in the household?

As you have reported zero income, who is helping you with financial responsibilities?

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Let’s talk about sex and health.

When was your last HIV test? *

Are you currently taking PrEP? *

In the last 72 hours, have you had condomless sex with a partner of unknown HIV status? *

When having sex, who are your typical partners? *

Men
Women
Transmen
Transwomen
Other

In the last 12 months, how many sexual partners have you had? *

What type of sex do you usually prefer? *

Top (insertive)
Bottom (receptive)
Vaginal
I prefer not to answer

In the last three months, have you had any sex without using a condom? *

To your knowledge, in the last three months, did you have sex with someone with HIV? *

Have you ever been diagnosed with any of the following STI’s?

Chlamydia Diagnosis *

Gonorrhea Diagnosis *

Syphilis Diagnosis *

Syphilis – How Long Ago were you diagnosed? *

Hepatitis A Diagnosis *

Hepatitis A – How Long Ago were you diagnosed? *

Hepatitis B Diagnosis *

Hepatitis B – How Long Ago were you diagnosed? *

Hepatitis C Diagnosis *

Hepatitis C – How Long Ago were you diagnosed? *

* Have you ever been diagnosed with any of the following? *

Kidney Disease
Diabetes
Liver Disease
None of the Above

Do you have any drug allergies? *

Drug Allergies, please specify *

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Thank You for considering CAN Community Health for your PrEP services.

Since you reported a possible exposure within the last 72 hours you must be evaluated for nPEP. (What is nPEP?) Please contact your nearest CAN Clinic immediately or visit the nearest emergency room to determine if you qualify for nPEP.

A CAN Community Health Representative might reach-out to you about your potential exposure.

Please visit www.cancommunityhealth.org/locations to find a CAN location near you.

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Click “Submit” below to finish your application for PrEP with CAN Community Health. Thank You for considering CAN Community Health for your PrEP services.

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