PrEP Consent To Ship

Welcome to Curant Health Pharmacy! We’re excited to partner with you on your PrEP journey. Starting PrEP is a powerful step toward protecting your health, and our compassionate pharmacy experts are here to make the process simple, supportive, and stress-free.

Complete the form below to finish your enrollment and authorize your first medication shipment. We’ll coordinate your delivery and send tracking information as soon as your medication is on the way.

Patient Acknowledgement / Signature Required Below

Consent To Ship - PrEP

Patient Name

First Name

Last Name

Patient Date of Birth

Please be sure to update the year to your birth year.

Patient Phone

Patient Email

Delivery Address

Street

Delivery Address

City

State/Province

Zip/Postal

Do You Have Any Allergies?

Yes

No

If Yes, Please List Any Medication or Other Allergies

Do You Have Prescription Insurance?

Yes

No

Upload Front of Insurance Card

Maximum file size: 6MB

Upload Back of Insurance Card

Maximum file size: 6MB

Medication Delivery

By checking this box, I understand that Curant Health will ship medications to the Delivery Address provided upon receipt of my initial prescription(s).

I authorize Curant Health to ship medications to the provided address for:

Please Choose One Option

Signature Required for Medication Delivery

No Signature Required for Medication Delivery

Right to Choose Pharmacy
By signing this form, I select Curant Health as my pharmacy. I understand that I have the right to choose the pharmacy from which I will receive medications and am not obligated to use Curant Health as my pharmacy. I also understand that I may discontinue using Curant Health at any time.

Release of Information & Consent to Ship Medications
By signing this form, I authorize Curant Health to (1) text me regarding medication updates and important information (2) contact my prescribing provider(s) to obtain new medication orders, (3) contact my current pharmacy to transfer existing prescriptions, if applicable, (4) permit Curant Health to ship medications to my requested Delivery Address.

Authorized Signature