Registration form PrEP care GGD Amsterdam

Please fill out this form if you want to receive PrEP care via the Public Health Service of Amsterdam (GGD Amsterdam). We will contact you if you are eligible to receive PrEP care from the Dutch National Programme.

The capacity to deliver PrEP care via the national programme at the GGD Amsterdam is limited. If possible, we ask you to initiate your PrEP care at a general practitioner. This way we can help those for whom that is not an option. Thank you for understanding.
More information is available at https://www.ggd.amsterdam.nl/english/sti-hiv-sense/prep/

Your data will be treated confidentially and in accordance with the Dutch Data Protection Act.

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

Flag as appropriate:

General conditions