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PATIENT/PROVIDER CONTRACT FOR PRE-EXPOSURE PROPHYLAXIS (PrEP)
Patient Name_________________________
Date_________________
Medical Provider
I have provided this patient the following:
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Assessment for possible acute HIV infection
Indicated laboratory screening to determine indications for these medications
An HIV risk assessment to determine whether PrEP is indicated for this patient
Medication facts listing dosing instructions and side effects, including adherence
Counseling on condom use and other appropriate HIV risk-reduction methods
Information about PrEP during contraception/pregnancy (if applicable)
A follow-up appointment
A prescription for Truvada (emtricitabine 200 mg/tenofovir 300mg) to be provided after lab
results are reviewed
As the provider, I will:
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Limit refill periods to recommended intervals for repeat HIV testing – every 3 months
Provide a “standing order” for a “walk-in” HIV lab test
Provide or have appropriate staff provide medication adherence assistance and counseling,
evaluation of STI symptoms, and risk-reduction counseling
Schedule medical appointment with labs every six months to discuss continued efficacy of PrEP
Patient
It has been explained to me that:
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Taking a daily dose of PrEP lowers my risk of acquiring HIV infection
If I miss a dose of my PrEP, I am less protected against HIV infection
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Not share my medication with anyone
Attend all scheduled appointments with my provider, including HIV testing every three months
Call WNCCHS at 285-0622 within 48 hours prior to any appointment if I cannot attend
Not receive a prescription for any medication without first seeing my PrEP provider and getting
tested for HIV
Work with my PrEP provider to establish at WNCCHS for primary care, if not already engaged in
primary care services elsewhere
Not hold my provider – or any provider I may see in relation to PrEP – responsible for any
negative issues or outcomes resulting from my failure to abide with the terms of this agreement
I understand that failing to abide by the terms of this agreement is grounds for discontinuation
of PrEP medications at WNCCHS
I understand that financial assistance with my PrEP medications may be available through
pharmaceutical assistance programs, and I will pay any co-pays, deductibles, or other associated
fees for my medications which are not covered by these pharmaceutical assistance programs, if
using the WNCCHS pharmacy
I agree to pay any co-pays, deductibles, or other associated fees in regards to my medical
appointments, lab fees, or other fees incurred at WNCCHS.
Patient Signature___________________________________
Date__________________
Provider Signature__________________________________
Date__________________