Register as PrEP Provider - My PrEP Locator

Information about your clinic & PrEP for HIV

The form is intended to collect information on your clinic and its ability to prescribe and/or provide PrEP to patients. Your cooperation is much appreciated.

PrEP Provider Application

If you are human, leave this field blank.

Clinic Details

Clinic name *

Email address *

Clinic contact number *

Clinic website link

Clinic Address

Address 1 *

Address 2

City *

Postcode *

State *

Hours of Operation

Monday

From

Hours of Operation

Tuesday

From

Hours of Operation

Wednesday

From

Hours of Operation

Thursday

From

Hours of Operation

Friday

From

Hours of Operation

Saturday

From

Hours of Operation

Sunday

From

HIV Connect Participant

Name of Doctor in Charge *

Registration No. of Doctor in Charge *

PrEP Service Details

Does a patient need a referral letter to be prescribed PrEP? *

Yes

Can a patient walk-in, or do patients need an appointment in advance? *

Walk-in

Appointment needed

Do you dispense PrEP onsite or offsite? *

Onsite

Offsite

Does your clinic provides PEP? *

Yes

If you dispense PrEP onsite, how much does a monthly supply of PrEP cost?

If PrEP is dispensed offsite, what pharmacy do you send patients to, to get PrEP?

How much does that pharmacy charge for a monthly supply of PrEP?

Please mark additional notes or instructions regarding your PrEP services here.

Subscription to Booking System

I would like to enable the Booking System for my clinic

I understand that I need to complete this Course to activate the Booking System

Terms of Use

I've read and agree to the Terms of Use *

I've read and agree to the Terms of Use

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