OraQuick HCV Rapid Test Kit Request
Imagine Hope HCV Project
Email address *
Name *
Your answer
Phone Number *
Your answer
Site Code *
Your answer
Worker ID *
Your answer
Facility *
Shipping Address *
Your answer
Is this a New Address?
Verification *
Please select all of the following
Required
How many Test Kits are you requesting?
Your answer
How many Controls are you requesting?
Once opened, controls are good for 8 weeks.
Your answer
You may request whatever quantity you need; if you are requesting more than 100, please explain:
Your answer
You agree that you: *
Yes
No
Have completed rapid HCV testing training.
Have been trained to use the OraQuick HCV Rapid Antibody Test.
Have been trained to do blood drawn HCV antibody testing
You agree that your agency: *
Yes
No
Conducts RNA confirmatory testing for each client who tests HCV Antibody positive
Reports all rapid HCV antibody testing and all RNA confirmatory testing to Imagine Hope.
Reports all positive HCV test results to SendSS.
Please allow two weeks for delivery
You will be notified by e-mail when your request can be filled.
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service