In-home HIV testing

Name/Nombre *

First

Last

Primero, Nombre de familia

Contact Phone/teléfono *

Email *

Street Address/Dirección *

City/Ciudad *

ZIP Code *

Comment or Message/Mensaje

Birth year/Año de nacimiento *

Race *

Ethnicity *

Gender Identity *

Sexuality *

Intravenous Drug Use *

How did you hear about In Home Testing from the Consortium? *

Other: (explain)

Have you heard of PrEP (Pre Exposure Prophylaxis)? *

Are you currently using PrEP? *

Have you used PrEP in the last 12 months? *

Permission to Contact *

By checking this box, I give the Delaware HIV Consortium permission to contact me about receiving the in-home HIV test kit offered by this program.

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