Testing - At-Home HIV Test Form

FREE At-Home HIV Test Kit

Please fill out the information below to receive your FREE At-Home HIV Test Kit by mail!
Your Information

Please complete all required fields. All information is kept strictly confidential.
Test Site
IMPORTANT: If you are currently experiencing a medical emergency or think you were exposed to HIV within the last 72 hours, please seek immediate care at your local emergency room or urgent care facility.
Today's Date*

MonthDayYear
Date
Your Name (first and last)*
Date of Birth*

MonthDayYear
Date
Age*
Phone Number*
Email Address*
To receive a follow-up survey
Mailing Address (USA only) *

Your Address

Street Address Line 2

CityState

Zip
County of Residence*
Assigned Sex at Birth*

MaleFemale
Current Gender Identity*

MaleFemaleTransgender (Male to Female)Transgender (Female to Male)Transgender UnspecifiedDeclineOther
Sexual Identity*

StraightBisexualGayLesbianPansexualAsexualOther
Race (select all that apply)*

AsianBlack/African AmericanWhiteNative AmericanNative Hawaiian/Pacific IslanderDon't Know/Not SpecifiedDeclineOther
Ethnicity*

Not Hispanic or LatinoHispanic or LatinoDecline
Past Medical & Social History

All information is kept strictly confidential.
Are you pregnant?*

YesNoUnknown
Have you ever been tested for HIV?*

YesNo
If yes, please provide an estimated date of your last HIV test (if N/A, skip to the next question)
Previous HIV Test Results (if N/A, skip to the next question)

NegativePositive
Have you ever been tested for Hepatitis C?*

YesNo
If yes, please provide an estimated date of your last Hepatitis C test (if N/A, skip to the next question)
Previous Hepatitis C Test Results (if N/A, skip to the next question)

NegativePositive
Have you ever had a sexually transmitted disease (STD/STI)?*

YesNo
If yes, please provide an estimated date of your positive STD/STI test (if N/A, skip to the next question)
Have you ever heard of PrEP (a medicine to prevent HIV)?*

YesNo
Have you taken PrEP in the last 12 months?*

YesNo
Are you currently taking PrEP?*

YesNo
Did you receive a blood transfusion or organ donation prior to 1992?*

YesNo
Have you ever been in direct contact with or exposed to another human's blood?*

YesNo
Have you ever received a tattoo or body piercing from an unlicensed facility?*

YesNo
Have you ever shared any type of needle or injected drugs/substances not prescribed by a physician?*

YesNo
Are you currently enrolled in a drug treatment facility or have been within the past 6 months?*

YesNo
Sexual History

All information is kept strictly confidential.
Within the past 5 years, I had sexual contact with a (select all that apply)*

MaleFemaleTransgender (Male to Female)Transgender (Female to Male)Other
Are you currently in a long-term relationship? (Married, partnered, or a mutually monogamous partner)*

YesNo
In the past 5 years, have you had more than 1 sexual partner?*

YesNo
In the past 5 years, have you had sex without using a condom?*

YesNo
In the past 5 years, have you had sex with an HIV positive partner?*

YesNo
Do you currently have health insurance?*

YesNo
Additional Resources
Would you like more information about PrEP?*

YesNo
Would you like more information about free condoms and other HIV/STD prevention resources?*

YesNo
Would you like more information about HIV, Hepatitis C, and STDs? (testing, treatment, and prevention information)*

YesNo
Would you like more information about the behavioral health services available at ARcare?*

YesNo
To receive the additional information requested above, please provide your email address below:
NOTE: An automated survey will be sent to your email in 14 days to rate your testing experience and share your test results. Your participation in this survey is essential to continuing this grant-funded testing program!
Acknowledgment

By signing below, I agree to the following statement:

"In accordance to state law, I understand all preliminary reactive test results must be reported to the Arkansas Department of Health."
Your Signature

Clear
How did you hear about us? (optional)
Examples: Social media, dating site, brochure, friend, ARcare staff (feel free to include their name for a shout out)
Please verify that you are human*
Should be Empty:

FREE At-Home HIV Test Kit

Your Information

Past Medical & Social History

Sexual History

Additional Resources