PreP appointment booking form PreP self referral form Note: Questions marked by * are mandatory *This is a mandatory field. Are you? Male Female Transgender Rather not say *This is a mandatory field. First name *This is a mandatory field. Surname *This is a mandatory field. Date of birth *This is a mandatory field. Address *This is a mandatory field. Postcode *This is a mandatory field. Mobile telephone number Appointment details are sent by text message. If this is a problem, please call 020 8296 3910. *This is a mandatory field. Can we leave a message on this number? Yes No *This is a mandatory field. Ethnicity Please Select An Option I do not wish to disclose thisWhite - BritishWhite - IrishAny other white backgroundBlack or Black British - CaribbeanBlack or Black British - AfricanAny other black backgroundAsian or Asian British - IndianAsian or Asian British - PakistaniAsian or Asian British - BangladeshiAny other Asian backgroundMixed - White and Black CaribbeanMixed - White and Black AfricanMixed - White and AsianAny other mixed backgroundChineseAny other ethnic group *This is a mandatory field. What is your country of birth? *This is a mandatory field. Which GP practice do you belong to? *This is a mandatory field. Do you require an interpreter? Yes No If yes, in which language? Yes No *This is a mandatory field. Are you currently on PrEP? *This is a mandatory field. Have you used PrEP before? Please list any medication you are taking Our routine PrEP follow-up appointments are on Friday mornings. *This is a mandatory field. Are you able to attend on a Friday morning? Yes No State preferred day of the week if unable to attend on a Friday morning. * Spam Guard: Is water wet or dry?
