CARES360 Community Clinic

Name*

First NameLast Name
Yes! I would like to be contacted by CARES 360 Community Clinic to discuss medical services.

This form is HIPAA Compliant and your personal information is protected.
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Assigned Sex at Birth:*

MaleFemale
Preferred Pronouns:*

She/her/hersHe/him/hisThey/them/theirOther
Sexual Orientation:*

Homosexual (Gay/Lesbian)Heterosexual (Straight)BisexualPrefer not to sayOther
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Check all services that interest you:

HIV CarePrEP (HIV Prevention)PeP (HIV Post-Exposure Prophylasis)STI Testing/TreatmentHepatitis C
Do you have health insurance?*

YesNo
If Yes, what kind of coverage do you have?

MedicaidMedicareCignaBlueCross BlueShieldAetnaAmBetterOther
Do you have any preferred provider? You may chose more than one.

Any available providerKassem Bourgi, MD -Nashville and MemphisRachel Davis, PA - NashvilleZach Campbell, NP - NashvilleRamona Moore, NP - MemphisGlenda Moses, NP - Memphis
By submitting this form, you agree to receive email and other communications from Nashville CARES and CARES 360 about events, programs, and updates.

You can unsubscribe at any time.
Should be Empty:

Yes! I would like to be contacted by CARES 360 Community Clinic to discuss medical services.