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Imaware Bulk Order Form
Thank you for your interest in accessing free imaware STI/HIV/VH kits. Please fill out the form below. All questions are mandatory. After submitting this form, someone from CDPHE will be revising your “distribution plan”, and making a decision on your order. Please allow up to 7 days for your order to be processed. CDPHE will notify you once your order has been approved and shipped. PLEASE NOTE: All ordres are sent via USPS
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E-Mail-Adresse *
Untitled Title
Agency Name *
Contact Name *
Phone Number *
Email Address *
Mailing Address: All orders are sent via USPS *
Indicate type of test kits you are requesting for those assigned female at birth.  *
Pflichtfrage
Indicate the number of tests you are requesting for those assigned female at birth *
Indicate type of test kits you are requesting for those assigned male at birth. 
 *
Pflichtfrage
Indicate the number of tests you are requesting for those assigned male at birth
 *
Date needed by
*Please remember that kits expire 6 months from the date they are shipped! This is because of the provider's standing order and not because of the date of expiration listed on the kit
 *
Datum
Describe, in detail, how these tests will be distributed. *
Describe your agency's plan to ensure individuals are returning their kits for processing *
Describe your agency's process for referrals to treatment and linkage to care *
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