HIV & STD Testing Request
Legal Name
*
First Name
Last Name
Do you go by a different name than your legal name?
*
Yes
No
Preferred Name
First Name
Last Name
Pronouns
*
She/Her
He/Him
They/Them
Zi/Zir
Do Not Wish to Disclose
Other
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
Example: 01/22/2023
Phone Number
*
Please enter a valid phone number.
Email Address
*
example@example.com
What is your race and/or ethnicity?
*
Black/African American
Hispanic/Latinx
White
Asian
American Indian/Alaska Native
Native Hawaiian/Pacific Islander
I Don't Know
Do Not Wish to Disclose
Other
How would you describe your gender identity?
*
Cis Man (Not Transgender)
Cis Woman (Not Transgender)
Transgender Woman
Transgender Man
Non-Binary
I'm Not Sure
Do Not Wish to Disclose
Other
How would you describe your assigned-at-birth sex?
*
Female
Male
Do not wish to disclose
How would you describe your sexuality/sexual orientation?
*
Heterosexual/Straight
Lesbian, Gay, Same Gender Loving
Bisexual
Pansexual
I'm Not Sure
Other
Do Not Wish to Disclose
How would you describe your use of condoms?
*
I always use condoms when having sex.
I use condoms most of the time when having sex.
I sometimes use condoms when having sex.
I never use condoms when having sex.
Have you had sex without a condom in the last month?
*
Yes
No
Have you had sex without a condom in the last three months?
*
Yes
No
Have you had sex without a condom in the last six months?
*
Yes
No
Have you had sex without a condom in the last year?
*
Yes
No
Have you been treated for an STD within the last six months?
*
Yes
No
Have you ever been tested for HIV?
*
Yes
No
Are you familiar with PrEP (Pre-Exposure Prophylaxis)?
*
Yes
No
Are you currently taking daily PrEP medication?
*
Yes
No
Have you used PrEP at any time in the last 12 months?
*
Yes
No
In the past 5 years, have you had sex with someone who identifies as a man?
*
Yes
No
In the past 5 years, have you had sex with someone who identifies as a woman?
*
Yes
No
In the past 5 years, have you had sex with someone who identifies as transgender?
*
Yes
No
In the past 5 years, have you injected drugs or substances?
*
Yes
No
In the past 5 years, have you worked as a sex worker?
*
Yes
No
Would you like to receive an emailed copy of this form?
*
Yes
No
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Testing Registration
Would you like to be tested for any of the following STIs in addition to HIV?
*
Chlamydia
Gonorrhea
No additional test
Which day or days of the week are you available to attend a testing appointment at TKO's office? (Select all available)
Monday
Tuesday
Wednesday
Thursday
Friday
Which times are you available to attend a testing appointment at TKO's office? (Select all available)
9 am - 11 am
11 am - 2 pm
2 pm - 5 pm
5 pm - 7 pm
How can we contact you to set up a testing appointment?
*
Text message
Phone call
Email
Phone Number
Please enter a valid phone number.
Are there any days where it isn't good to contact you via phone call or text message?
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
What time of day are we likely to reach you by phone or text message?
Early Morning: 8am - 10am
Mid Morning: 10am - 12pm
Early Afternoon: 12pm - 3pm
Late Afternoon: 3pm - 5pm
Early Evening: 5pm - 7pm
Late Evening: 7pm - 9pm
Are you interested in enrolling in PrEP services through TKO?
*
Yes
Unsure
No
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Do you need access to any of the following services?
Gender-affirming healthcare (including hormone therapy, surgeries, etc.)
Gender-affirming legal services (name change, birth certificate change, driver's license change, etc.)
Gender-affirming personal supplies (perfume/cologne, makeup, packers, binders, bras, etc.)
Housing
Employment/Income
Health Insurance
Mental/Behavioral Health
Food
Other
Provide keywords for other social services needs
What is the most severe housing status you experienced in the last 12 months?
Literally homeless
Unstably housed or at risk of losing housing
Stably housed
Declined to Answer
Do you have health insurance?
Yes
No
Unsure
Submit
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