Rapid HIV Test Kit Order Form

Rapid HIV Test Kit Order Form

For HAHSTA Official Partners use
Pickup Location

2201 Shannon Place SE Washington DC 20020
Contact Information
Organization*
Name*

First NameLast Name
Will testing be performed in a clinical or non-clinical setting?*
Clinical: Hospital, Community health center, STD clinic, Emergency Department Non-clinical: community setting, School, Shelter/transitional housing, Public area, Syringe Exchange Program, Mobile Unit
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
OraQuick HIV Tests and Controls
Number of OraQuick HIV Boxes (100 tests per box)
1 box = 100 tests
Do you need an OraQuick control?

YesNo
Number of OraQuick In-Home HIV Boxes (6 tests per box)*
INSTI Tests and Controls
Number of INSTI Boxes (50 tests per box)
1 box = 50 tests
Do you need an INSTI Control?

YesNo
Request a pick-up date and time

Pick Up Dates are currently Tuesdays and Wednesdays 9am-3pm
Appointment*
Provide Name and Contact Information of Designated Pick-Up Person*

Terms of Use
By submitting a request form, you are agreeing to the GetCheckedDC data use terms. Information submitted in GetCheckedDC request forms and feedback surveys will be collected in Jotform, which is a database compliant with the Health Insurance Portability and Accountability Act of 1996. All web-based data transmissions are encrypted, and user access is restricted on a role-specific basis. GetCheckedDC will retain and share certain data elements for program research and development but will not share personally identifiable information (e.g., name, email address, mailing address). If you have any questions or concerns, send an email to dchealth.testingorders@dc.gov*

I agree to the terms above.
Please verify that you are human*
ordered_date

MonthDayYear
Hour MinutesAM/PM Option
Should be Empty:

Pickup Location