Acts Pharmacy and Healthcare Services

1
Patient's Full Legal Name* This field is required.
First Name
Ml
Last Name
2
Date of Birth:* This field is required.
Month
Day
Year
3
Phone Number* This field is required.
4
Email: (Please make sure this is typed correctly to receive confirmation email)* This field is required.
example@example.com
5
What is your sex assigned at birth?* This field is required.
Male
Female
Intersex
Unknown
Refused
6
What is your gender?* This field is required.
Male
Female
Trans-Female to Male
Trans-Male to Female
Nonbinary
Unknown
7
What pronouns do you use?* This field is required.
She/Her/Hers
He/Him/His
They/Them/Theirs
Refused
Other
8
Address:* This field is required.
Street Address Line 2
United States
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
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Dominican Republic
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El Salvador
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Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
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Guadeloupe
Guam
Guatemala
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Guinea
Guinea-Bissau
Guyana
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Hungary
Iceland
India
Indonesia
Iran
Iraq
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Israel
Italy
Jamaica
Japan
Jersey
Jordan
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Kenya
Kiribati
North Korea
South Korea
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Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
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Sao Tome and Principe
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Senegal
Serbia
Seychelles
Sierra Leone
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Slovenia
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Somaliland
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South Ossetia
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eSwatini
Sweden
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Tajikistan
Tanzania
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Tokelau
Tonga
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Tunisia
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Uruguay
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Vanuatu
Vatican City
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Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
9
How did you hear about us?* This field is required.
Website
TPCHD
AIDS Healthcare Foundation (AHF)
Provider referral
Rainbow Center
Other
10
Do you have insurance?
YESNO
11
Insurance Card Photo
12
We highly encourage you to apply for financial assistance through the PrEP DAP program to cover any copays you might incur. Please visit the Washington Department of Health website to initiate the process. https://doh.wa.gov/you-and-your-family/illness-and-disease-z/hiv/prevention/pre-exposure-prophylaxis-prep
13
The purpose of this section is to authorize ACTS Pharmacy to release/obtain information from the following sources:* This field is required.
Your local county Health Department
Tacoma-Pierce County Health Department
Washington State Department of Health
AIDS Healthcare Foundation (AHF)
Previous/Current PrEP Provider (if applicable)
Primary Care Provider
Rainbow Center
Gilead Advancing Access
Community Health Care
Planned Parenthood
Other
14
Authorization* This field is required.
I authorize the release of my complete records (including records relating to mental health, drug/alcohol, HIV/AIDS and other sexually transmitted infections, and Health Insurance)
15
If you answered to authorize the release of you complete record above with exception, please list those exceptions below:* This field is required.
16
Signature of Patient/Legal Guardian * This field is required.
Clear
17
All information is confidential and is accessed only via a secure, encrypted interface.
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