At-Home HIV/STI Kit
Consent form
Contact Information
Preferred Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Can we text you at this phone number?
*
Yes
No
Email
*
example@example.com
Are you a current patient of Spectrum Medical?
*
Yes
No
A Spectrum Medical Outreach Navigator will be in touch to process your request.
Would you prefer to complete the assessment over the phone or via email?
*
Have an outreach navigator call me.
Email me the assessment form and I will return it via email.
Submit
Should be Empty: