After-Hours HIV/STI Test Site Intake Form
(After-Hours Testing will continue May 2026, if you need walk in testing, please call 801-823-1988 opt.1, Monday-Friday 8am-3pm, to check availability)
Legal Name
*
First Name
Last Name
Preferred Name
Pronouns
Date of Birth
*
-
Month
-
Day
Year
Date
Are you between the age of 18 and 34?
*
Yes
No
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you have health insurance? / ¿Usted tiene seguro?
*
Yes/Si
No
Ethnicity / Grupo ètnico:
*
Hispanic/Hispano, Latino
Not Hispanic/No Hispano, Latino
Don't know/No Sè
Race/Raza:
*
American Indian/Alaska Native – Indígena Americano
Asian/Asian American - Asiático/Asiático Americano
Black/African American – Negro/Afroamericano
White/European American –Blanco/Euroamericano
Hawaii Native/Pacific Islander – Nativo de Hawaii/Isl. Del Pac
Don’t Know/No Sé
Sex assigned at birth / Sexo:
*
Male/Varon
Female/Hembra
Prefer not to answer
Gender / Género
*
Man/Hombre
Woman/Mujer
Non-Binary/No binario (a)
Transgender
Other
Who do you have sex with? / ¿Usted tiene relaciones sexuales con? Check all that apply.
*
Men/Hombres
Women/Mujeres
Transgender and Non-binary people
Other
What types of sexual encounters do you have?
*
Vaginal Receiving
Vaginal Giving
Anal Receiving
Anal Giving
Oral Receiving
Oral Giving
In the past 12 months have you used injection drugs?
*
Yes
No
UAF participates in a Syringe Exchange Program. Would you like any injection supplies? (Syringes, cookers, containers, etc.) All are free, but please note you must have at least one used syringe to exchange for new supplies.
Yes
No
In the past 12 months, have you bought, sold or traded sexual services for money or something else you needed?
*
Yes
No
Would you like to talk with someone on how to reduce your risks for HIV/STIs while buying, selling, or trading sexual services?
Yes
No
In the last 12 months, have you been a victim of sexual violence?
*
Yes
No
Maybe/Don't know
Would you like to be connected with resources regarding your experience?
Yes
No
In the past 12 months, have you or any of your sexual partners tested positive for Gonorrhea or Syphilis?
*
Yes
No
Don't know
Have you had sex, or are you currently having sex, with a person who is HIV positive?
*
Yes
No
Don't know
Are you, or any of your sexual partners, pregnant?
*
Yes
No
Don't know
Are you, or any of your sexual partners within the last 12 months, between the ages of 15 and 24?
*
Yes
No
Don't know
In the past 12 months, have you had sex without a condom?
*
Yes
No
In the past 12 months, have you had more than 1 sexual partner?
*
Yes
No
Have you had an HIV test before?
*
Yes
No
What is the approximate date of your last HIV test?
-
Month
-
Day
Year
Date
What is your HIV status?
*
Positive
Negative
Don't know
Do you know what PrEP (Pre-Exposure Prophylaxis) is?
*
Yes
No
PrEP is a once daily medication that has been shown to be up to 99% effective at preventing an HIV infection when used consistently. At your appointment, would you like more information on PrEP's effectiveness, side effects, and cost, or a referral to a provider who can prescribe PrEP?
*
Yes
No
Are you currently taking PrEP?
*
Yes
No
At your appointment, would you like more information on PrEP's effectiveness, side effects, and cost, or a referral to a provider who can prescribe PrEP?
*
Yes
No
Have you taken PrEP anytime in the last 12 months?
*
Yes
No
May we leave a message on your voicemail, send a text, or email with personal health information?
*
Yes
No
Would you like to talk with someone about any questions or concerns related to your sexual health?
*
Yes
No
Below are some ideas of topics we can discuss. Select (or write in) what you would like to address.
HIV/STI transmission routes
Prevention methods (condoms, communication, testing, PrEP, etc)
Communication with partners (condom negotiation, testing and sexual history, etc)
How to have safer sex while under the influence of drugs and alcohol
Is it safe to have sex with someone who is HIV+
Consent
Other
Would you like any condoms? All are free.
Traditional Latex
XL Latex
Latex Free
Dental Dams
At the time of your appointment, would you like help deciding which tests may be best for you?
*
Yes (I would like help deciding which tests to get)
No (I know what tests I'd like)
Please select which test(s) you'd like:
*
Rapid HIV Test (Free)
Chlamydia & Gonorrhea Urine Test ($25)
Chlamydia & Gonorrhea Rectal Swab ($25)
Chlamydia & Gonorrhea Oral Swab ($25)
Syphilis ($15)
Have you been diagnosed with syphilis in the past?
*
Yes
No
What is the approximate date you were diagnosed?
*
-
Month
-
Day
Year
Date
Where were you diagnosed? Please list city and state, as well as the specific clinic if you know it.
If you would like your results sent to your provider, please provide as much contact information as you can:
Please select a date and time for your appointment. Questions? Email maya.jowers@uafhealth.org
*
How did you hear about testing at UAF?
*
I've been here before
Friends
Google/Internet
Social Media
Dating/Hookup apps
Outreach event
What can we do to improve?
UAF Legacy Health offers affirming primary care for all, HIV prevention/treatment, gender-affirming care, mental health, and STI services—are you insured and interested in establishing care?
Yes
No
Please review UAFLH Notice of Privacy Practices:
Terms and Conditions
*
Please review UAFLH Consent for Testing and Treatment Agreement:
Terms and Conditions
*
I agree and understand that all electronic signatures are the legal equivalent of my manual/handwritten signature and I consent to be legally bound to this agreement.
*
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