Post-exposure prophylaxis (PEP) Form

Name

Surname

Phone Number

ID Number

Have you used our services before?

Address

City

Postal Code

Are you 18 years or older?

Is your weight more than 30kg?

Are you HIV positive?

Do you have kidney disease or reduced kidney function?

Do you have liver disease?

Do you have any allergies to HIV medication including e.g. Tenofovir (TDF), Lamivudine (3TC) or Dolutegravir (DTG)?

Are you pregnant or breastfeeding/ expressing breastmilk?

Are you using any of these medications?

When did the potential exposure to HIV occur?

Is the source person HIV-positive? (the person that you suspect has exposed you)

What type of exposure occurred?

I have read and agree to the Terms and Conditions and Privacy Policy (POPI) of the use of this Website and Service. I understand the questions above and have answered honestly. I understand that any inaccurate or false information could potentially be dangerous to my health and safety. The medication that is prescribed is for my personal use only. I understand the side effects and effectiveness of the treatments.I agree to the Terms & Conditions of this platform.I am 18 years or older.I am currently living in Zimbabwe

I Agree to the terms and conditions of this Prescription Application and that of the use of this service.

BROWSE PRESCRIPTIONS

MENU

US$ 10,00