At-Home HIV Test Request

At-Home HIV Testing Form

Fill out the form carefully to request your At-Home HIV Test
Client Name

First Name Middle Name Last Name
Birth Date

Month Day Year
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
E-mail
example@example.com
Phone Number

Area Code Phone Number
Prefered Delivery Method

Pick up kit from Aliveness Drop off kit to my residence Mail kit to my residence (Great MN Only)
Additional Comments
Should be Empty:

At-Home HIV Testing Form