HRC HIV Testing Kit Request Form

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* 1. Name

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* 2. Phone Number

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* 3. Zip code

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* 4. Race/Ethnicity

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* 5. Gender Identity

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* 6. Sexual Orientation

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* 7. Age Group

Under 15

15-25

26-35

36-45

46-55

56-65

66-75

75+

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* 8. Date of Birth

Date / Time

Date

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* 9. How did you hear about the Self-Testing Kit

Other (please specify)

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* 10. Do you need a testing Kit shipped to your home?