HIV Testing Form - Updated September 2024

HIV Testing Form

Please be sure to complete this very short form to receive your HIV test. If yo would like an At-Home Test Kit, please double-check your address so that we can send your kit to the right person and location.
For more information about the FDA approved rapid self-test for HIV, please download the document.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County (NOT Country)*
Phone Number*
Email*
example@example.com
Ethnicity*

Hispanic/LatinoNon Hispanic/Latino
Race*

American Indian/Alaska NativeAsianBlack/African AmericanNative Hawaiian/Pacific IslanderWhiteNot SpecifiedDeclined to Answer
Assigned Sex at Birth*

MaleFemale
Current Gender/Identity*

MaleFemaleTransgender (male to female)Transgender (female to male)Transgender (unspecified)Another GenderDeclined to Answer
Have you ever heard of PrEP (Pre-Exposure Prophylaxis)?*

YesNo
Are you currently taking daily PrEP medication?*

YesNo
Have you used PrEP anytime in the last 12 months?*

YesNo
In the past 5 years, have you had sex with a MALE?*

YesNo
In the past 5 years, have you had sex with a FEMALE?*

YesNo
In the past 5 years, have you had sex with a transgender person?*

YesNo
In the past 5 years, have you injected drugs or substances not prescribed by a doctor?*

YesNo
Did you receive a blood transfusion or organ donation prior to 1992?*

YesNo
Have you ever been on long-term hemodialysis?*

YesNo
Have you ever been employed in a medial or dental field involving direct contact with human blood*

YesNo
Have you ever been treated for a sexually transmitted disease?*

YesNo
Have you ever received a tattoo or body piercing from an unlicensed facility?*

YesNo
Have you ever had an HIV test done previously?*

YesNo
Have you ever tested positive for an HIV test previously?*

YesNo
What year did you test positive for an HIV test previously?*
Have you ever had an Hepatitis C (HCV) test done previously?*

YesNo
Have you ever tested positive for a Hepatitis C (HCV) test previously?*

YesNo
What year did you test positive for a Hepatitis C (HCV) test previously?*
Were you treated for Hepatitis C (HCV)?*

YesNo
Have you ever taken a syphilis test?*

YesNo
Have you ever tested positive for a syphilis test?*

YesNo
Were you treated for syphilis?*

YesNo
Do you feel you need assistance in obtaining health benefits?*

YesNo
Do you believe your sexual behavior causes you to be more likely to be exposed to sexually transmitted diseases like HIV, HEP C, syphilis, gonorrhea, etc?*

YesNo
Do you feel you need any assistance with behavioral health services such as therapy?*

YesNo
How did you hear about our At Home testing opportunity?*

Radio AdvertisementFacebookInstagramTiktokLinkdInYouTubeNewspaperFuture Builders, Inc. WebsiteFriend or FamilyHealth Fair or Other EventOther
This test will use an oral mouth swab that you will rub against your gums. You should not eat or drink at least 30 minutes prior to taking the test. If you have dentures, you will need to remove them before taking the test. Do you understand this information?*

YesNo
Thank you for completing this form. The information within it is confidential and only Future Builders will have access to it. This is the first step to the HIV testing process. Once you submit this form, you will receive your testing kit in the mail. Do you understand this process?*

YesNo
This is a preliminary test. If you receive preliminary positive results, we will work with the Arkansas Department of Health and health care providers to get you an appointment to confirm the results. It is essential you share with us your results. Do you understand the information that has been shared?*

YesNo
Please enter any additional information you would like to share with Future Builders, Inc. Anything at all.*

YesNo
If you have requested an at-home test kit, we would love for you to work with one of our Community Health Workers as you take your HIV test. If you choose to do so, we will send you a gift card in the mail after your results. For us to work with you, please select a date and time for us to call you and take your test with you.
We have four office locations. Which are you closest to?

Pulaski County, Wrightsville, ARJefferson County, Pine Bluff, AR
Signature

Clear
Should be Empty: