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PrEP is one pill taken daily that is 99% effective at the prevention of HIV. With LuxRx you'll be securely connected online with a licensed physician and complete all required PrEP lab testing from the comfort of your home. Whether you have insurance or not, we got you covered! That’s right, your telehealth visit, labs, STI testing and Prep medication are free!

PrEP Sign Up Form

Please fill out the following form
and someone will contact you in 24-48 hours for next steps. All information you provide is kept strictly confidential and secure, and only used to determine the appropriate course of care for you.

First Name

Last Name

Nickname

Referred By (Promo Code)

Email

Date of Birth

State

Zip Code

SEX ASSIGNED AT BIRTH? *

MALE

FEMALE

PREFERRED PRONOUNS? *

He/Him/His

She/Her/Hers

They/Them/Their

GENDER IDENTITY? *

Male

Female

Transgender Male

Transgender Female

Gender Queer

Gender Nonconforming

If you answered yes to any question, please elaborate

Initials

I declare that the info I’ve provided is accurate & complete

Select an option

Choice 1

Choice 2

Choice 3

Thanks for submitting!

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