HIV Self Test Kit
Interest Form

Thanks for your interest in our at

home, in your space HIV Testing Program

Please fill out the information below and one of our team members will reach out to you to schedule your drop! You will hear back within 1 business day. We are closed on the weekends.

Name

First Name

Last Name

What are your pronouns?

Safe phone number to contact you at about an HIV self test kit delivery

(###)

###

####

Email Address

Date of Birth

YYYY

Zip Code

Race

Ethnicity

Sexual Orientation

Gender Identity

When was your last HIV test?

How did you hear about us?

Comments/Notes

I give my consent for JASMYN to contact me to schedule a HIV self test kit delivery. I also give consent for my information to be maintained in JASMYN’s internal and confidential electronic database so JASMYN can contact me.

Yes

No (If no, we can not contact you)

We need to know if you have already received your kit. Are you filling out this form AFTER you have already received an HIV Self Test Kit?

HIV Self Test KitInterest Form

Thanks for your interest in our at

home, in your space HIV Testing Program

HIV Self Test Kit
Interest Form