HIV and Syphilis Self-Testing Kit Request Form

Thank you for your interest in the self-testing kits!

Please complete this form to request an HIV and/or syphilis self-testing kit.

Please note the following:

1. Self-testing kits can only be sent to Broward County addresses.

2. If you have previously been diagnosed with syphilis, the syphilis self-testing kit is not appropriate for you.

3. Your personal information will remain confidential and will only be used to process your request.

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* 1. Full Name

First Name

Last Name

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* 2. Shipping Information

Street Address

City

State

ZIP Code

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* 3. Email

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* 4. Phone Number

Country Code

Phone Number

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* 5. Age

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* 6. Race/Ethnicity

Non-Hispanic White

Non-Hispanic Black

Hispanic

Asian

Native Hawaiian/Pacific Islander

American Indian/Alaskan Native

Other

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* 7. What self-testing kit are you requesting?

Please keep in mind that the syphilis self-testing kit is only appropriate for those who have never received a positive syphilis diagnosis.

HIV Only

Syphilis Only

HIV and Syphilis

HIV and Syphilis Self-Testing Kit Request Form

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* 1. Full Name

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* 2. Shipping Information

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* 3. Email

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* 4. Phone Number

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* 5. Age

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* 6. Race/Ethnicity

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* 7. What self-testing kit are you requesting? Please keep in mind that the syphilis self-testing kit is only appropriate for those who have never received a positive syphilis diagnosis.

* 7. What self-testing kit are you requesting?

Please keep in mind that the syphilis self-testing kit is only appropriate for those who have never received a positive syphilis diagnosis.