Registration form PrEP care

 

Please fill out this form if you want to receive PrEP care via the Public Health Service of the Hague (GGD Haaglanden). We will contact you if you are eligible to receive PrEP care from the Dutch National Programme.

The capacity to deliver PrEP care via the national programme at GGD Haaglanden is limited. If possible, we ask you to initiate your PrEP care at a general practitioner. This way we can help those for whom that is not an option. Thank you for understanding.

Your data will be treated confidentially and in accordance with the Dutch Data Protection Act.

More information on www.mantotman.nl


Questions marked with a * are  mandatory

dd-mm-yyyy
4 numbers without the letters, if you do not have a permanent residence: enter “0001”

General conditions

I declare that I completed this form truthfully and am aware that this may be checked during my appointment. I am aware that an appointment is no guarantee for participation in the PrEP Care programme via GGD Haaglanden.