Prevention Supplies Request

  • Prevention Request

  • Which Prevention Resources would you like to Request? (Choose all that apply)*
  • What kind of HIV Testing are you interested in?*
  • How did you hear about our Prevention Supplies program?*
  • Which App/site did you find us through?
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • How would you prefer to be contacted?*
  • Date of Birth*
     - -
  • Race (choose as many as apply)*
  • Have you had an HIV test Previously?*
  • Is there a particular reason you would like to be tested?*
  • Have you ever heard of PrEP? (Pre Exposure Prophylaxis)*
  • PrEP is a once-daily medication that is 99.9% effective at preventing a person from contracting HIV. It is considered to be as safe as Aspirin, and is often available at no cost. Corktown Health Center offers PrEP Navigation services, where a navigator can assist you with accessing PrEP. Would you be interested in speaking with a navigator to learn more?*
  • Would you be interested in being referred to a PrEP Navigator who can assist you with accessing PrEP?*
  • Is there a particular reason why you are not interested in PrEP?*
  • Are you currently taking Daily PrEP Medication?*
  • Have you used PrEP any time in the last 12 months?*
  • In the past 5 years, have you had sex with a male?*
  • In the past 5 years, have you had sex with a female?*
  • In the past 5 years, have you had sex with a person who is Transgender?*
  • In the past 5 years, have you injected drugs or substances?*
  • Do you Have Health Insurance?*
  • Do you have secondary insurance?*
  • What is your secondary insurance type? (check all that apply)*

  • Corktown Health has Insurance Navigators who can assist you with applying for Medicaid, Medicare, or Marketplace Insurance plans.  For insurance assistance, please call us at (313) 832-3300 and ask to speak to extension 227

  • CONSENT FORM FOR THE HUMAN IMMUNODEFICIENCY VIRUS (HIV) ANTIGEN AND/OR ANTIBODY TEST

  • I have been informed that an oral sample from my mouth will be tested for antibodies to the Human Immunodeficiency Virus, the virus that causes AIDS.

    I acknowledge that I have been given an explanation of the test, including it's uses, benefits, limitations, and the meaning of the test results.

    I have been informed that the HIV test results are confidential, and shall not be released without my written permission, except as required under state law.

    This test will be performed confidentially.  I understand that my Personally Identifying Information will be provided to the Michigan Department of Health and Human Services regardless of result.

    I understand that I have the right to withdraw my consent for the test at any time before the test is complete.

    I acknowledge that I will be provided with a copy of the pamphlet "What You Need to Know about HIV Testing." I will be given the opportunity to ask questions concerning the test for HIV antigens and/or antibodies, and I understand that my questions will be answered by the test counselor.

    I understand that I will be contacted by a Corktown Health test counselor for follow-up.

    A signed copy of this consent form will be included with my test kit.

    By my signature below, I consent to be tested for HIV

  • Today's Date*
     / /
  • Type of Safer Sex Kit (Due to inventory shortage, we can only give 10 condoms):
  • Attempt 1
     - -
  • Attempt 2
     - -
  • Attempt 3
     - -
  • Kit Mailed
     - -
  • Logged into Aphirm
     - -
  • Follow-up Contact
     - -
  • Should be Empty: