Prevention Supplies Request

Have you had an HIV test Previously?*

YesNo

Is there a particular reason you would like to be tested?*

Regular testingI am experiencing STI SymptomsI have recently learned that a previous sexual partner tested positiveOther

Have you ever heard of PrEP? (Pre Exposure Prophylaxis)*

YesNo

PrEP is a once-daily medication that is 99.9% effective at preventing a person from contracting HIV. It is considered to be as safe as Aspirin, and is often available at no cost. Corktown Health Center offers PrEP Navigation services, where a navigator can assist you with accessing PrEP. Would you be interested in speaking with a navigator to learn more?*

YesNo

Would you be interested in being referred to a PrEP Navigator who can assist you with accessing PrEP?*

YesNo

Is there a particular reason why you are not interested in PrEP?*

Are you currently taking Daily PrEP Medication?*

YesNo

Have you used PrEP any time in the last 12 months?*

YesNo

In the past 5 years, have you had sex with a male?*

YesNo

In the past 5 years, have you had sex with a female?*

YesNo

In the past 5 years, have you had sex with a person who is Transgender?*

YesNo

In the past 5 years, have you injected drugs or substances?*

YesNo

Do you Have Health Insurance?*

YesNo

What is your primary Insurance type?*

Do you have secondary insurance?*

YesNo

What is your secondary insurance type? (check all that apply)*

Do you need any assistance obtaining Health benefits, such as Insurance, Medicaid, Medicare, or Prescription assistance? (If yes, please describe)*

Do you need any assistance obtaining health benefits, such as Insurance, Medicaid, Medicare, or Prescription assistance?*

Corktown Health has Insurance Navigators who can assist you with applying for Medicaid, Medicare, or Marketplace Insurance plans. For insurance assistance, please call us at (313) 832-3300 and ask to speak to Triage or extension 107

Would you like to be linked to any risk reduction interventions such as peer support groups, syringe service programs, etc? (if yes, please describe)*

Do you need any assistance obtaining behavioral health care, such as a Therapist or medication to treat any mental illness? (If yes, please describe)*

Do you have any other supportive social services needs such as food or clothing banks, housing assistance, applying for SNAP benefits that we may be able to assist you with? (If yes, please describe)*

I wish to have this test performed:

I have been informed that an oral sample from my mouth will be tested for antibodies to the Human Immunodeficiency Virus, the virus that causes AIDS.

I acknowledge that I have been given an explanation of the test, including it's uses, benefits, limitations, and the meaning of the test results.

I have been informed that the HIV test results are confidential, and shall not be released without my written permission, except as required under state law.

This test will be performed confidentially. I understand that my Personally Identifying Information will be provided to the Michigan Department of Health and Human Services regardless of result.

I understand that I have the right to withdraw my consent for the test at any time before the test is complete.

I acknowledge that I will be provided with a copy of the pamphlet "What You Need to Know about HIV Testing." I will be given the opportunity to ask questions concerning the test for HIV antigens and/or antibodies, and I understand that my questions will be answered by the test counselor.

I understand that I will be contacted by a Corktown Health test counselor for follow-up.

A signed copy of this consent form will be included with my test kit.

By my signature below, I consent to be tested for HIV

Signature*

Today's Date*

Date

Prevention Request

CONSENT FORM FOR THE HUMAN IMMUNODEFICIENCY VIRUS (HIV) ANTIGEN AND/OR ANTIBODY TEST