HIV Post-Exposure Prophylaxis Inquiry Form

Your E-mail (required):

Your name (optional):

Your phone (optional):

Exposure Type:

If sexual:

Was a condom used?

Type of sex involved (Check all that apply):
 receptive anal intercourse "bottom" insertive anal intercourse "top" oral sex insertive vaginal intercourse receptive vaginal intercourse other exposure route

What is the HIV status of the person who exposed you?:

What is your HIV status?:

Please enter the characters shown below: