At-Home HIV Test Kit Request Form
At Home Test kits will not be shipped during the month of April, if you need a rapid HIV test, please call 801-823-1988
Legal Name
*
First Name
Last Name
Preferred Name
Pronouns
Date of Birth
*
-
Month
-
Day
Year
Date
Are you between the age of 18 and 34?
*
Yes
No
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you have health insurance? / ¿Usted tiene seguro?
*
Yes/Si
No
Ethnicity / Grupo ètnico:
*
Hispanic/Hispano, Latino
Not Hispanic/No Hispano, Latino
Don't know/No Sè
Race/Raza:
*
American Indian/Alaska Native – Indígena Americano
Asian/Asian American - Asiático/Asiático Americano
Black/African American – Negro/Afroamericano
White/European American –Blanco/Euroamericano
Hawaii Native/Pacific Islander – Nativo de Hawaii/Isl. Del Pac
Don’t Know/No Sé
Sex assigned at birth / Sexo:
*
Male/Varon
Female/Hembra
Prefer not to answer
Gender / Género
*
Man/Hombre
Woman/Mujer
Non-Binary/No binario (a)
Transgender
Other
Who do you have sex with? / ¿Usted tiene relaciones sexuales con? Check all that apply.
*
Men/Hombres
Women/Mujeres
Transgender and Non-binary people
Other
What types of sexual encounters do you have?
*
Vaginal Receiving
Vaginal Giving
Anal Receiving
Anal Giving
Oral Receiving
Oral Giving
In the past 12 months have you, or any of your sexual partners, used injection drugs?
*
Yes
No
Would you like any injection supplies? (Syringes, cookers, containers, etc.) All are free.
Yes
No
In the past 12 months, have you bought, sold or traded sexual services for money or something else you needed?
*
Yes
No
Would you like to talk with someone on how to reduce your risks for HIV/STIs while buying, selling, or trading sexual services?
Yes
No
In the last 12 months, have you been a victim of sexual violence?
*
Yes
No
Maybe/Don't know
Would you like to be connected with resources regarding your experience?
Yes
No
In the past 12 months, have you or any of your sexual partners tested positive for Gonorrhea or Syphilis?
*
Yes
No
Don't know
In the last year have you had sex, or are you currently having sex, with a person who is HIV positive?
*
Yes
No
Don't know
Are you, or any of your sexual partners, pregnant?
*
Yes
No
Don't know
Are you, or any of your sexual partners within the last 12 months, between the ages of 15 and 24?
*
Yes
No
Don't know
In the past 12 months, have you had sex without a condom?
*
Yes
No
In the past 12 months, have you had more than 1 sexual partner?
*
Yes
No
Have you had an HIV test before?
*
Yes
No
What is the approximate date of your last HIV test?
-
Month
-
Day
Year
Date
What is your HIV status?
*
Positive
Negative
Don't know
Do you know what PrEP (Pre-Exposure Prophylaxis) is?
*
Yes
No
PrEP is a once daily medication that has been shown to be up to 99% effective at preventing an HIV infection when used consistently. At your appointment, would you like more information on PrEP's effectiveness, side effects, and cost, or a referral to a provider who can prescribe PrEP?
*
Yes
No
Are you currently taking PrEP?
*
Yes
No
At your appointment, would you like more information on PrEP's effectiveness, side effects, and cost, or a referral to a provider who can prescribe PrEP?
*
Yes
No
Have you taken PrEP anytime in the last 12 months?
*
Yes
No
May we leave a message on your voicemail, send a text or email with personal health information?
*
Yes
No
Would you like to talk with someone to address any questions or concerns related to your sexual health?
*
Yes
No
Below are some ideas of topics we can discuss. Select (or write in) what you would like to address.
HIV/STI transmission routes
Prevention methods (condoms, communication, testing, PrEP, etc)
Communication with partners (condom negotiation, testing and sexual history, etc)
How to have safer sex while under the influence of drugs and alcohol
Is it safe to have sex with someone who is HIV+
Consent
Other
Would you like any condoms? All are free.
Traditional Latex
XL Latex
Latex Free
Dental Dams
At the time of your appointment, would you like to talk with someone to help determine which tests are most appropriate?
*
Yes (I would like help determining which tests to get)
No (I know what tests I'd like)
Please select which test(s) you'd like:
*
Rapid HIV Test (Free)
Syphilis ($15)
Chlamydia & Gonorrhea Urine Test ($25)
Chlamydia & Gonorrhea Oral Swab ($25)
Chlamydia & Gonorrhea Rectal Swab ($25)
Have you been diagnosed with syphilis in the past?
*
Yes
No
What is the approximate date you were diagnosed?
*
-
Month
-
Day
Year
Date
Where were you diagnosed? Please list city and state, as well as the specific clinic if you know it.
If you would like your results sent to your provider, please provide as much contact information as possible:
Please select a date and time for your testing appointment. Appointments help maintain a smooth flow so you can be seen sooner and get out faster. You will receive a reminder test the morning of your appointment:
*
Are there other services we can help connect you with?
Mental Health referral
Social services (Domestic Violence, food pantries, etc)
Other
How did you hear about testing at UAF?
*
I've been here before
Friends
Google/Internet
Social Media
Dating/Hookup apps
Outreach Event
What can we do to improve?
Please review UAFLH Notice of Privacy Practices
Please review UAFLH Consent for testing and treatment agreement:
By signing your legal name below, you state that you understand the testing procedures and give consent to all testing. You also certify that you are a current resident of Utah.
*
Submit
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