OraQuick HCV Rapid Test Kit Request
Imagine Hope HCV Project
Email address *
Name *
Phone Number *
Site Code *
Worker ID *
Facility *
Address *
City *
Zip Code *
Is this a New Address?
Verification *
Please select all of the following
Required
How many Test Kits are you requesting?
HCV test kits come in boxes of 100
How many Controls are you requesting?
Once opened, controls are good for 8 weeks.
You may request whatever quantity you need; if you are requesting more than 200, please explain:
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.
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