At-Home HIV test request

What is the name you would like your HIV Test Kit addressed to? *

First Name Last Name
What is a phone number where you can be reached? *
Please enter a valid phone number.
Email
example@example.com
How would you prefer to be contacted? *

Phone Call Text Message Email
Where would you like your HIV Test Kit mailed? *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

CONSENT FORM FOR THE HUMAN IMMUNODEFICIENCY VIRUS (HIV) ANTIGEN AND/OR ANTIBODY TEST
I have been informed that an oral sample from my mouth will be tested for antigens and/or 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 to: blanks and as permitted under state law.
I wish to have this test performed: *

Confidentially - I understand that my personally identifying information will be provided to the Michigan Department of Health and Human Services regardless of result. Anonymously - I undertand that my personally identifying information will be provided to the Michigan Department of Health and Human Services only in the event of a reactive 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 *

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Date *

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Date
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At-Home HIV Test request

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