FREE oral Self-Test for HIV Order Form         
en Español

Please complete this Order Form to received your FREE HIV Self Test Kit!
  • a $45 value AT NO COST to you
  • To be used in the next 3 weeks after receiving the test kit
  • We follow-up with you in 3 weeks to hear about your experience and answer any questions.
  • For more information, please visit https://www.pridecenterflorida.org/wellness/
  • IF YOU HAVE A REFERRAL/PROMO CODE YOU WILL BE ASKED FOR IT ON A LATER SCREEN.
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       The Wellness With Pride Program offers a FREE oral HIV Self Test (a $45 value) at no cost to you. Test at home, with a friend, or wherever you feel comfortable. No blood needed - just an oral swab and results are ready in 20 minutes!  

       If you have been hesitant to test, or are concerned with confidentiality, this service maybe helpful. You DO NOT need to disclose your results to us. 

       We can only mail tests to Florida addresses, and you must be at least 18 years old. 
* This test is not appropriate for people who already know they are living with HIV.  In this case, to check if your medications are working, you need a viral load test available from your doctor.
First Name *
Last Name *
Your Address:

(We can only mail Self Tests to Florida addresses)
Please enter the address where in Florida you want to receive your Free HIV Self Test
Street Address with apt/unit (Must be in Florida) *
City (Must be in Florida) *
Zip Code (5 Digits) *
County (Select One) *
Zoom Assistance? *
Would you like help from a representative of The Pride Center with performing your Self Test via Zoom? 
(If yes, we will call you to set up a time to perform the test over Zoom)
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