HIV Self Test Kit Order Form

Contact Name
Email
Phone
Consent for us to process information:
Consent to contacy if faults w/ Playpack:
Consent to contact re order new Playpack:
Postal Address:
Postal Postcode:
Current Age:
Gender Identity:
Gender Identity - Please State:
Your gender identity the same at birth?:
Sexual Orientation:
Sexual Orientation - Other, Please State:
Ethnicity:
Ethnicity - Other, Please State:
Who do you have sex with?:
Describe partner(s) you have sex with?:
What kinds of sex do you do?:
Method(s) of protection use during sex?:
Method(s) of Protection - Other, Please:
Have you been tested for HIV before?:
If tested before, when was recent test?:
have you been tested for STI's before?:
Most recent STi test in months:
Been diagnosed with an STI in past year?:
Would you like a text reminder to test?:
Confident & comfortable testing for HIV?:
Like to contact you about our services?:
Been vaccinated for Hepatitis A & B?: