OraQuick® In-Home HIV Test request form

OraQuick® In-Home HIV Test request form
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
Please provide a valid email address for Choice Health Network staff to send shipping confirmation of your in-home HIV test.
Birthday*

MonthDayYear
Gender*
Race*
Ethnicity*
County*
Housing Status*
Health Insurance *
Possible ways you may have contracted HIV. Check as many as applicable.*

No risk identifiedInjecting substancesSnorting substancesMultiple sex partnersPrevious and/or recent positive text result for another sexually transmitted infection (STI)Sex with someone who has HIVSex with menSex with womenSex with other genders
Previous HIV test result*
How recent was your potential exposure?*
If your most recent exposure was within 72 hours, post-exposure medication is available. Please call us at 865-525-1540 or visit your nearest emergency room.
Please read and check the box next to each statement to request your in-home HIV test.*

I understand that my agreement to be tested is voluntary.I understand that there is some level of risk that information in text messaging could be read by someone other than myself.I understand that positive test results will be reported to the Tennessee Department of Health.I understand that there is a period of up to 90 days after exposure, and it is recommended to retest if a negative result is received before the 90-day window.I understand that antibodies are the body’s reaction to foreign substances, and that this test is approximately 98% accurate if taken 90 days after exposure.I understand that if my test result is reactive/positive, further testing will need to be performed for confirmation.I understand that I will receive follow-up text messages from a prevention team member to report my test result.
By typing my name and the date below, I verify my consent for Choice Health Network to mail an in-home HIV test to the address provided above.
Signature*
Date*

MonthDayYear
Signature*
Should be Empty:

OraQuick® In-Home HIV Test request form

If your most recent exposure was within 72 hours, post-exposure medication is available. Please call us at 865-525-1540 or visit your nearest emergency room.

By typing my name and the date below, I verify my consent for Choice Health Network to mail an in-home HIV test to the address provided above.