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At-Home HIV Testing Form
Please be sure to complete this very short form to receive your At-Home HIV test. Double-check your address so that we can send your kit to the right person.
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Email
*
Your email
First Name
*
Your answer
Last Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Home Address (just street or PO Box)
*
Your answer
City
*
Your answer
State (spelled out)
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Your answer
Zip Code
*
Your answer
County (please enter COUNTY, NOT COUNTRY)
*
Your answer
Phone Number (please enter a working number including the area code)
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Your answer
Email Address (please enter an address you check regularly and have the password)
*
Your answer
Ethnicity
*
Hispanic/Latino
Non Hispanic/Latino
Race
*
American Indian/Alaska Native
Asian
Black/African American
Native Hawaiian/Pacific Islander
White
Not Specified
Declined to Answer
Other:
Assigned Sex at Birth
*
Male
Female
Other:
Current Gender/Identity
*
Male
Female
Transgender (male to female)
Transgender (female to male)
Transgender (unspecified)
Another Gender
Declined to Answer
Other:
Have you ever heard of PrEP (Pre-Exposure Prophylaxis)?
*
Yes
No
Are you currently taking daily PrEP medication?
*
Yes
No
Have you used PrEP anytime in the last 12 months?
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Yes
No
In the past 5 years, have you had sex with a male?
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Yes
No
In the past 5 years, have you had sex with a female?
*
Yes
No
In the past 5 years, have you had sex with a transgender person?
Yes
No
Clear selection
In the past 5 years, have you injected drugs or substances?
*
Yes
No
Have you ever had an HIV test done previously?
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Yes
No
Do you feel you need assistance in obtaining health benefits?
*
Yes
No
Do you believe your sexual behavior causes you to be more likely to be exposed to sexually transmitted diseases like HIV, HEP C, syphilis, gonorrhea, etc?
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Yes
No
Do you feel you need any assistance with behavioral health services such as therapy?
*
Yes
No
How did you hear about our At Home testing opportunity?
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Radio Advertisement
Facebook
Instagram
Tiktok
LinkdIn
YouTube
Newspaper
Future Builders Website
Friend or Family
Other:
Required
This test will use an oral mouth swab that you will rub against your gums. You should not eat or drink at least 30 minutes prior to taking the test. If you have dentures, you will need to remove them before taking the test. Do you understand this information?
*
Yes
No
Thank you for completing this form. The information within it is confidential and only Future Builders will have access to it. This is the first step to the HIV testing process. Once you submit this form, you will receive your testing kit in the mail. Do you understand this process?
*
Yes
No
Other:
This is a preliminary test. If you receive preliminary positive results, we will work with the Arkansas Department of Health and health care providers to get you an appointment to confirm the results. It is essential you share with us your results. Do you understand the information that has been shared?
*
Yes
No
Please enter any additional information you would like to share with Future Builders, Inc. Anything at all.
Your answer
Please type your name for a signature.
*
Your answer
A copy of your responses will be emailed to the address you provided.
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