Request Kit

CLIENT ID:
AGF NUMBER:
Registration Form

Fill out the form carefully for registration
Have you requested an Self Test Kit before?*

YesNo
Date*

MonthDayYear
Date
Birth Date*

MonthDayYear
Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County*
Race*
Ethnicity*

Hispanic or LatinoNot Hispanic or Latino
Sex Assigned at Birth*

MaleFemale
Sexual Orientation*
Mobile Number*
Format: (000) 000-0000.
E-mail
example@example.com
- Date of last sexual encounter:*
  
  MonthDayYear
  Date
- *
  
  With CondomWithout Condom
- Have you ever heard of PrEP (Pre-Exposure Prophylaxis)?*
  
  YesNo
- Currently on PrEP or have taken PrEP?*
  
  YesNo
- Have you used PrEP any time in the last 12 months?*
  
  YesNo
- Type of Sex:*
  
  OralVaginalAnal(receptive)Anal(insertive)
- Number of partners in the past 2 months:*
- Number of partners in the past 12 months:*
- Known STIs you have had in the last 5 Years.:*
  
  SyphilisGonorrheaChlamydiaHIVNone
- Risk Factors*
  
  Baby BoomerClose Contact (type: sex, household other)HomelessnessMultiple Sex PartnersMen who Have Sex with MenOccupational blood exposurePiercingsSharing Needles / WorksTattoosUnwanted Sexual ExperiencesYou or partners in jail/prisonBlood Products prior to 1992DialysisNeedle StickOrgan TransplantProstitutionSex with a person who has HIV/AIDSSurgery / DentalTravel (US or outside US)No Risk
- In the past 30 days have you had unprotected sex with a(n):*
  
  MaleFemaleTransgenderMultiple partnersMen who have sex with menHIV positive personExchange for drugsPerson who injected drugsNo known sexual risk factors
- Risks in the past 12 months:*
  
  MSMIllicit drug useFemale sex with an MSMMultiple sex partnersSex for money/drugs or Commercial sexHistory of STD(s)No known sexual risk factors
- Have you had an HIV test previously?*
  
  YesNoDon't Know
- Result*
  
  NegativePositive
- Year Last Tested:*
  
  MonthDayYear
  Date
- Would you like a test for any of the following STI's (Check all that applies)
  
  ChlamydiaGonorrheaTrichomoniasisSyphillisHepatitis C
- Vaginal or Anal Sex with a Male:*
  
  YesNoDON'TKNOW
- Vaginal or Anal Sex with a Female:*
  
  YesNoDON'TKNOW
- Vaginal or Anal Sex with a Transgender Person:*
  
  YesNoDON'TKNOW
- Have you ever heard of PrEP (Pre-Exposure Prophylaxis)?*
  
  YesNo
- Are you currently taking daily PrEP medication?*
  
  YesNo
- Have you used PrEP anytime in the last 12 months?*
  
  YesNo
- Are you discontinuing PrEP today?*
  
  YesNo
- Have you had any exposure to HIV in the past 72 hours?*
  
  YesNo
- Signature*
- Should be Empty:

Registration Form