RITM Manila HIV Testing Request Form
If you are interested in undergoing an HIV test, you may complete this form to send us a request! We promise that we will keep your identity private. We suggest you complete this form rigorously for us to able to address your needs more specifically.
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Name *
How should we call you?
Preferred means of communication *
You can choose one or both.
Required
Mobile number
Communication via mobile phone is the most convenient for us. You may choose to disclose your mobile phone number here. We promise to keep your number confidential.
E-mail Address
You may also choose to correspond with us via an e-mail address
Do you want to go for an HIV test? *
What is keeping you from getting yourself tested for HIV? *
Check all that apply to you.
Required
City of Residence *
Tell us where you live, so we can direct you to the nearest testing location/s.
City of Work
Tell us where you work, which might be more convenient for you as we choose your testing location.
When talking to someone, your most preferred language is/are
Choose the language/s you are most comfortable with.
Submit
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