In Home HIV Test Request by Mail - for Idaho residents only

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You may also text or call 208-991-4574 ext. 1 to get more information about HIV testing and PrEP referrals.

Initials (first two letter of first name, first two letter of last name) *

Date of Birth *

YYYY

Phone number *

This would allow for us to contact you if the package gets returned or to follow up with you regarding results.

Is it ok to leave a message at this number? *

Yes

Full Name

This is optional, but it may ensure that the test gets delivered to the address and the correct resident.

Address *

Please include city, state and zip code. Must be an Idaho resident.

Risk assessment

Man who has sex with men

Intravenous drug use

Known exposure to HIV

Other:

Have you ever been tested for HIV in the past? If so, how long ago?

Less than a month ago

Less than 6 months ago

6 months to 1 year ago

1-3 years ago

3-5 years ago

More than 5 years ago

Other:

Clear selection

The result of my most recent HIV test was:

Positive

Negative

Other:

Clear selection

Clear form

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