HIV Self Test Kit Form

The OraQuick Oral Antibody test is performed by placing the swab on the lining of your month Results take 20 minutes. If you have any questions, please contact the Florida department of Health at testing@knowyourhivstatus.com.

Please note we can only ship to a Florida address.

Shipping Information

First Name*

Last Name*

Street Address (Valid Address Only, No P.O. Box)*

City*

County*

ZIP Code*

State (Florida residents only)*

Email*

Phone Number*

I give consent to DOH for using this email to communicate electronically.*

Demographics

Are you a Florida resident?*

Yes

Please Identify your Race*

Please Identify your Ethnicity*

Country of Birth*

Age*

Please Identify your Gender*

When were you last tested for HIV?*

If you were referred by an organization, please provide the name below

Select to double this order

Were you referred to this site by a local organization?

Yes