PrEP-zorg

Registration form PrEP care GGD Amsterdam

The National PrEP program of the GGD Amsterdam has limited capacity. U can apply for the waiting list. PrEP care is also available through your general practitioner.

For more information please see https://www.ggd.amsterdam.nl/english/sti-hiv-sense/prep/

This form is secure and your information will be treated confidentially.

Personal data

First name

Surname / family name

Date of birth

dd-mm-yyyy

Zipcode

4 numbers without the letters, if you do not have a permanent residence: enter “1000”

Telephone number

Email address

Gender

Man

Woman

Do you feel different than the gender you were assigned at birth?

Yes

Flag as appropriate:

As far as I know, I do not have HIV

In the past 6 months, I have been diagnosed with syphilis or an anal STI

In the past 6 months I have used PEP (Post Exposure Prophylaxis)

In the past 6 months I have had anal sex without a condom with someone of whom I do not know their HIV status or who I know is HIV positive and has a detectable viral load

I do not have health insurance

I have sex in exchange for money or goods

In the past 5 years, I have migrated to the Netherlands from a non-Western country. )

General conditions

I meet the following registration criteria:

I declare that I completed this form truthfully and am aware that this may be checked during my appointment. I am aware that an appointment is no guarantee for participation in the PrEP Care programme via GGD Amsterdam.

Other declarations of consent

Your choice regarding the statements below does not influence whether or when you are invited for an appointment.

I hereby agree that the information registered in this form can be linked to my patient record of the Centre for Sexual Health (“soa-poli”).

I hereby give permission to be contacted for the purpose of scientific research in the future.