Utah AIDS Foundation Tele-Testing Intake Form
At-Home HIV/STI Testing
Legal First Name
Legal Last Name
Date of Birth
Not Hispanic/No Hispano, Latino
Don’t Know/ No Sè
American Indian/Alaska Native – Indígena Americano
Asian/Asian American - Asiático/Asiático Americano
Black/African American – Negro/Afroamericano
White/European American –Blanco/Euroamericano
Hawaii Native/Pacific Islander – Nativo de Hawaii/Isl. Del Pac
Don’t Know/No Sé
Do you have insurance? / ¿Usted tiene seguro?
What types of sexual encounters do you have (Check all that apply)
Sex Assigned At Birth/Sexo
Prefer not to answer
Do you have sex with (Check all that apply) /¿Usted tiene relaciones sexuales con:
Transgender and Non-binary people
What test(s) would you like?
Chlamydia & Gonorrhea Oral Swab (2 week window period)
Chlamydia & Gonorrhea Rectal Swab (2 week window period)
Chlamydia & Gonorrhea Urine (2 week window period)
OraQuick In-Home HIV Test (3 month window period)
Have any of your sexual partners from the past 4 weeks tested positive for Chlamydia, Gonorrhea, or Syphilis?
Are you or any of your current sexual partners pregnant?
Are you or any of your sexual partners within the last year between the ages of 15 and 24?
May we leave a message on your voicemail or send a text with personal health information? / Podemos dejar un mensaje en el buzón de voz con la información personal de salud ?
What is your preferred method of communication to receive the date and time of your counseling session as well as the meeting code for your counseling session?
If you would like to set up a video call with Blake to talk about any sexual health questions you may have, please select what dates you would be available. If you are getting an HIV test, this is required.
If you would like your results sent to your doctor please provide their name, office fax number, and office phone number
Payment for Testing. Everyone will pay $15 for shipping. HIV tests are free. If you are doing Chlamydia and Gonorrhea testing it will be a $25 flat rate regardless of how many sites you are testing.
( X )
Chlamydia and Gonorrhea Testing
it is $25 whether you are getting 1, 2 or 3 sites.
Credit Card Details
Credit Card Number
By signing your legal name below you state that you have read through the entire at home testing instructions on our webpage, understand the testing procedure, and give consent to all the testing you have selected above.
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