Prescription Assistance Application

First Name *

Last Name *

Email *

Phone *

Driver License or Government I.D. Number *

Do you have medical insurance?

Yes

No

If you have medical insurance, who is your medical provider? (Enter “N/A”, if you answered “No” above.)

Are you employed?

Yes

No

Chronic Illnesses

Diabetes

Yes

No

High Blood Pressure/Heart Disease

Yes

No

Other

Have you ever been tested for

HIV

STI

Date Tested for HIV

Date Test for STI

Client Advocate will make copies of all items received during the Intake Process….

I Consent to Receive Emails, SMS Notifications, Alerts, & Occasional Marketing Communication from THAPgroup, Tampa-Hillsborough Action Plan, or Synergy Health Centers (SHC). Message frequency varies. Message & data rates may apply. Text HELP to (813) 550-0999 for assistance. You can reply STOP to unsubscribe at any time. *

Yes

No