Register for the ePharmacy

Free Text

Personal Information

First Name:

Last Name:

Preferred Name:

Cell Number:

Date of Birth:

Gender:

City/Suburb:

Province:

Free Text

Other Information

Do you identify as any of the following?

Do you know your HIV status?

Where did you hear about PrEP?

Campaign Code:

Free Text

Informed Consent

Free Text

The programme offers you the option of getting your medication from our ePharmacy partner (CareWorks). You can register with the ePharmacy to have your medication delivered directly to your door. Your information will be shared with CareWorks who will contact you for registration if you wish to opt-in for this service.

Registration form