Health Access Hub Appointment Request
Contact Information
First Name
Last Name
Phone Number
Email Address
Date of Birth
Preferred Contact Method
Phone
Text
Email
Our team is available Monday through Friday, 9:30 AM–6:30 PM.
Preferred Day to Contact
Please select...
Monday
Tuesday
Wednesday
Thursday
Friday
No Preference
Best Time to Contact
Please select...
Anytime during business hours
9:30 AM – 11:30 AM
11:30 AM – 1:30 PM
1:30 PM – 3:30 PM
3:30 PM – 5:00 PM
5:00 PM – 6:30 PM
Please contact me by email
Are you completing this form for yourself?
Yes
No
Person You Are Assisting
Name of the person you're assisting
Your relationship to this person
Please select...
Parent/Guardian
Spouse/Partner
Family Member
Friend
Caregiver
Case Manager/Social Worker
Community Partner
Other
Health Access Hub Appointment Request
Location
ZIP Code
County
Please select...
Fulton
Barrow
Bartow
Butts
Carroll
Cherokee
Clayton
Cobb
Coweta
Dawson
DeKalb
Douglas
Fayette
Forsyth
Gwinnett
Haralson
Heard
Henry
Jasper
Lamar
Lumpkin
Newton
Meriwether
Morgan
Paulding
Pickens
Rockdale
Spalding
Walton
How Can We Help?
What type of assistance are you looking for?
Please select...
HIV testing
STI testing
PrEP information or starting PrEP
PrEP follow-up
PEP after a possible HIV exposure
Sexual health education/counseling
Other sexual health concern
I'm not sure — I'd like help deciding
How soon do you need assistance?
Today
Within a few days
Within a week
Within a month
Just looking for information
Please tell us more about your situation.
Health Access Hub Appointment Request
How Did You Hear About Us?
How did you hear about P.O.W.E.R. ATLANTA?
Please select...
Search Engine
Social Media
Friend or Family
Community Event
School
Healthcare Provider
Faith Organization
Another Nonprofit/Agency
Existing Client
Other
Consent & Submit
Review your information before submitting your request.
May P.O.W.E.R. ATLANTA contact you regarding this request?
Yes
No
Communication Permission
I agree to be contacted regarding my request for assistance.