At-Home Test Request

Request a FREE At-Home HIV Test

Thank you for your interest in receiving a FREE At-Home HIV Test from Engaging Arkansas Communities! We need to collect some basic information below to be able to send you a test in the mail. You must live in the state of Arkansas to receive a test kit through our service. Please answer all questions. Your information is always kept confidential according to strict HIPAA guidelines.
Do you live in the state of Arkansas?*

YesNo-If you live outside Arkansas, we are not able to mail you a test kit. Please do not complete this form if you live outside the state of Arkansas.
First and Last Name*

First NameLast Name
Birth Date*

MonthDayYear
Preferred Language*

EnglishSpanish
Phone Number*

Area CodePhone Number
Are you able to receive text messages at this phone number?*

YesNo
IMPORTANT:

If you have been exposed to HIV by a broken condom, subjected to sexual violence, or shared a needle within the past 48 hours, please contact your doctor or Emergency Room immediately.
Have you been exposed to HIV in the past 48 hours?*

I have not been exposed in the past 48 hours.I have been exposed in the past 48 hours.Submit
E-mail*
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Gender*

MaleFemaleTrans ManTrans WomanTransgender (unspecified)Gender-FluidNon-BinaryOther
Sexual Identity*

Straight or HeterosexualGayBisexualLesbianPansexualAsexualTwo-SpiritedOther
Do you identify as Hispanic or Latino?*

YesNo
Race (Check all that apply)

American Indian / Alaskan NativeAsianBlack / African AmericanNativ Hawaiian / Pacific IslanderWhite / CaucasianOther
How long has it been since your last HIV test?*

Less than 1 month2-6 months7-12 monthsMore than 12 monthsI have never been tested
What might have put you at risk for HIV? (Check all that apply)*

Vaginal or anal sex with a femaleVaginal or anal sex with a female without condomVaginal or anal sex with a transgender personVaginal or anal sex with a transgender person without condomVaginal or anal sex with a maleVaginal or anal sex with male without condomInjection drug useAccidental needle stickBlood ExposureSexual activity with HIV positive partnerYour sexual partner engages in condom-less sex with other sexual partnersYour sexual partner uses injection drugsOther
Which best describes your use of PrEP (Pre-Exposure Prophylaxis?*

I do not know about PrEP.I take PrEP sometimes.I take on-demand PrEP around sexual activity.I have heard of PrEP, but never taken it.I take PrEP once a day as perscribed.I was taking PrEP, but am not now.Other
Free Condoms & Lube

For those who are eligible to receive an at-home test kit in the mail, we can also send a small offering of condoms and/or lube FREE OF CHARGE, while supplies last. Supply is based on current stock and available funding. Some restrictions apply.
Do you need condoms or lube?*

I need condoms only.I need condoms and lube.I do NOT need condoms or lube.
Would you also like internal/female condoms?*

Yes, please send a few internal condoms.No, I don't need internal condoms.
How did you learn about EAC's At-Home HIV Testing Program?*

Brochure or PrintDating App (Grindr, Scruff, Tindr)Facebook or InstagramGoogle or Online SearchPodcastReferred by friendReferred by staff at EACSpecial EventWebsite - Arkansas Resource HubWebsite - Engaging Arkansas CommunitiesOther
Let us know how it went and get a FREE Gift Card!

***Fill out a brief survey after the at-home test and you will be eligible to receive a FREE gift card!*** You will receive a confirmation email with important information from us. Details will be in your confirmation email.
Should be Empty:

Request a FREE At-Home HIV Test

IMPORTANT:

Free Condoms & Lube

Let us know how it went and get a FREE Gift Card!