• FREE At-Home HIV Test Kit

    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.

  • 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*
     / /
  • Date of Birth*
     / /
  • Format: (000) 000-0000.
  • Assigned Sex at Birth*
  • Current Gender Identity*
  • Sexual Identity*
  • Race (select all that apply)*
  • Ethnicity*

  • Past Medical & Social History

    All information is kept strictly confidential.
  • Are you pregnant?*
  • Have you ever been tested for HIV?*
  • Previous HIV Test Results (if N/A, skip to the next question)
  • Have you ever been tested for Hepatitis C?*
  • Previous Hepatitis C Test Results (if N/A, skip to the next question)
  • Have you ever had a sexually transmitted disease (STD/STI)?*
  • Have you ever heard of PrEP (a medicine to prevent HIV)?*
  • Have you taken PrEP in the last 12 months?*
  • Are you currently taking PrEP?*
  • Did you receive a blood transfusion or organ donation prior to 1992?*
  • Have you ever been in direct contact with or exposed to another human's blood?*
  • Have you ever received a tattoo or body piercing from an unlicensed facility?*
  • Have you ever shared any type of needle or injected drugs/substances not prescribed by a physician?*
  • Are you currently enrolled in a drug treatment facility or have been within the past 6 months?*

  • Sexual History

    All information is kept strictly confidential.
  • Within the past 5 years, I had sexual contact with a (select all that apply)*
  • Are you currently in a long-term relationship? (Married, partnered, or a mutually monogamous partner)*
  • In the past 5 years, have you had more than 1 sexual partner?*
  • In the past 5 years, have you had sex without using a condom?*
  • In the past 5 years, have you had sex with an HIV positive partner?*
  • Do you currently have health insurance?*

  • Additional Resources

  • Would you like more information about PrEP?*
  • Would you like more information about free condoms and other HIV/STD prevention resources?*
  • Would you like more information about HIV, Hepatitis C, and STDs? (testing, treatment, and prevention information)*
  • Would you like more information about the behavioral health services available at Arcare?*

  • 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." 

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