Rapid HIV Test Kit Order Form
For HAHSTA Official Partners use
Pickup Location
2201 Shannon Place SE Washington DC 20020
Contact Information
Organization
*
Please Select
Bread for the City
C3 Cares
Community Family Life Services
Comprehensive Psychiatric Emergency Program (DBH)
Damien Ministries
DC/Maryland Safe Haven
DC Health & Wellness Center
DC Safe Haven
Family Medical Counseling Services (FMCS)
Gallaudet University Student Health Service
HBI-DC
HIPS
Howard University
La Clinica del Pueblo
Latin American Youth Center (LAYC)
Medstar Georgetown
One Tent Health
So Others Might Eat (SOME)
StreetHealth DC
Terrific Inc.
The Women’s Collective
Us Helping Us (UHU)
Washington Health Institute (WHI)
Whitman Walker Health (WWH)
Name
*
First Name
Last Name
Will testing be performed in a clinical or non-clinical setting?
*
Please Select
Clinical
Non-clinical
Both
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.
Format: (000) 000-0000.
OraQuick HIV Tests and Controls
Number of OraQuick HIV Boxes (100 tests per box)
1 box = 100 tests
Do you need an OraQuick control?
Yes
No
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?
Yes
No
Rapid HCV Tests
Available for limited time only. Maximum of 3 per organization.
Number of HCV Test Kits (100 per box)
1 box = 100 tests
Do you need an HCV Control?
Yes
No
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
*
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