Apretude Enrollment Form
Form will be automatically sent to Sunray Specialty Pharmacy for processing. Please send an electronic prescription along with this form to avoid delays.
Patient's Name
*
First Name
Last Name
Patient's Date of Birth
*
-
Month
-
Day
Year
Date
If patient has Medicare, please include last 4 numbers of patient's social security number so that insurance information can be searched:
Patient's Gender
*
Please Select
Male
Female
Non-Binary
Prefer Not To Disclose
Patient's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Patient's Height
*
Patient's Weight
*
Allergies to Medications
*
Concomitant Medications
*
Prescriber
*
PrEP Navigator
Is this the initiation dose or a maintenance dose?
*
Initiation Dose or restart (administer once monthly x 2 months)
Maintenance Dose (administer every other month)
When do you plan to administer the Apretude?
-
Month
-
Day
Year
Date
Delivery Address for Apretude
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
When would you like Apretude to be delivered to the office?
*
-
Month
-
Day
Year
Date
Upload proof of negative HIV test or fax to (215)471-4001
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Upload LFTs (if available) or fax to (215)471-4001
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