PrEP (Pre-Exposure Prophylaxis) is a HIV Prevention Tool. To learn more about the GPHA PrEP Services and if PrEP is right for you, please complete the form below. Fields marked with an * are required First Name * Last Name * Preferred Name * Email Address * Phone * Street Address City * State * - Select State - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Washington DC ARMED FORCES AFRICA \ CANADA \ EUROPE \ MIDDLE EAST ARMED FORCES AMERICA (EXCEPT CANADA) ARMED FORCES PACIFIC Zip * 5 of 5 Date of Birth (Please use MM/DD/YYYY format) * Preferred Language * American Sign Language Arabic English French Mandarin Spanish Other Can we text the phone number listed above? Y/N * Yes No Can we send emails to the address listed above? * Yes No What is your Gender * M F MTF FTM GQ/NB Other Decline to answer What are your pronouns? * She/Her He/Him They/Theirs Other Can we leave voice messages on the number listed above? Y/N * Yes No Is this a share email address? * Yes No How do you identify? * Hetero/Straight Bi or Pansexual Queer Asexual Don't Know Other Decline to answer How did you hear about us? * GPHA website Postcard mailing or Flyer Referred by a provider, friend, or family member SEPTA Decline to Answer Other HTML PrEP Awareness Have you ever heard of PrEP? * Yes No Don't Know Decline to Answer Are you interested in oral PrEP? * Yes No Don't Know Decline to Answer Are you currently on PrEP? * Yes No Don't Know Decline to Answer Are you interested in injectable PrEP? * Yes No Don't Know Decline to Answer You can help make this program better! Check here if it's okay to contact you in the future. HTML If you have any questions, please feel free to contact us GPHA PrEP Services at 215-671-6833 M-F 8:30 A-5 P/EST or via email at PrEP@gphainc.org. If you are a human seeing this field, please leave it empty.