Check Coast - TEST Intake Form

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STI & HIV Testing Intake

ProTecht Private, Encrypted | Usually takes 3–5 minutes
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Complete this confidential intake to request STI and/or HIV testing through Check Coast Clinic. Select all of the tests you're interested in below. Our care team will review your information and confirm the appropriate testing options and next steps.
Email

Confirmation Emailexample@example.com
What would you like to be tested for? (Select all that apply)
original_intent
branch_path
pep_hiv_status_at_intake
pharmacy_assigned
payment_status
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Choose the testing option you prefer. A team member will confirm availability, location, timing, and any applicable cost before your visit.
How would you prefer to complete your testing?
How soon would you prefer to complete your testing?

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COST & COVERAGE
We'll review any coverage, cost, and payment options that may apply to your testing before services are provided.
How would you like us to review medication coverage?

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CONSENT & SIGNATURE

Please read and sign the following:
Notice of Privacy Practices

Please review our Notice of Privacy Practices before providing your acknowledgment below.
I acknowledge that I received or had the opportunity to review the Notice of Privacy Practices.
I consent to the collection of specimens and testing for the HIV and/or sexually transmitted infection (STI) tests requested or determined appropriate as part of my care. I understand that additional or repeat testing may be recommended based on my history, timing of possible exposure, symptoms, or test results.
I understand that test results will be reviewed by the care team and that I may be contacted regarding my results, follow-up testing, treatment, or other recommended care.
I consent to receive care through telehealth. I understand the potential benefits, risks, and limitations; that an in-person evaluation may be recommended; and that I may withdraw consent as allowed by law without losing the right to future care.
I understand that this service is not for emergencies. If I believe I am experiencing a medical emergency, I will call 911 or go to the nearest emergency department.
I consent to evaluation and treatment and authorize One Check Away, Inc. and its Check Coast Clinic to disclose information to healthcare providers, laboratories, pharmacies, health plans, and other persons or entities as permitted by law for treatment, payment, and healthcare operations.
Full Legal Name

First NameMiddle NameLast NameSuffix
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hour MinutesAM/PM Option
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STI & HIV Testing Intake

Patient Information`

Testing & Exposure Information

COST & COVERAGE

CONSENT & SIGNATURE