At-Home HIV Testing Request Form
By entering my information here, I am requesting that Legacy Community Health call me regarding in-home HIV testing.  

Completing this request does not mean an HIV test kit will automatically be sent. A Legacy Community Health representative will contact you for a more detailed screening call to ensure that this service will best suit your needs.

After the screening call, we will mail the test kit to you. It may take 3-5 days after the screening call before you receive your free kit.
Sign in to Google to save your progress. Learn more
First Name: *
Last Name: *
Preferred Language? *
Which language are most comfortable speaking & could understand medical terms in?
Date of Birth *
You must be 17 years of age or older to receive an in-home HIV test from Legacy.
MM
/
DD
/
YYYY
Assigned Sex at Birth *
Gender *
Ethnicity & Race *
Choose all that apply.
Required
Sexual Orientation *
Do you have a private and secure physical mailing address (a Post Office Box is not acceptable) to send the in-home HIV test kit? *
How did you hear about the at-home test kit? *
Street Address: *
City: *
Zip code: *
Phone Number *
Please set-up your voicemail (or clear it), so that Legacy staff may leave you a voicemail if we miss you.  
Email *
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy