Test Request Form Name(Required) First Last Address(Required) Street Address Address Line 2 City Tennessee State ZIP Code Phone(Required)Email(Required) Please provide a valid email address for Positively Living & Choice Health Network staff to send shipping confirmation of your at-home HIV test kit.Birthdate(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender(Required)MaleFemaleTransgenderAnother genderGender(Required)Race(Required)WhiteBlack/African AmericanAsianNative American/Alaska NativeNative Hawaiian/Pacific IslanderEthnicity(Required)Hispanic/LatinxNon-Hispanic-LatinxCounty(Required)AndersonBedfordBentonBledsoeBlountBradleyCampbellCannonCarrollCarterCheathamChesterClaiborneClayCockeCoffeeCrockettCumberlandDavidsonDecaturDeKalbDicksonDyerFayetteFentressFranklinGibsonGilesGraingerGreeneGrundyHamblenHamiltonHancockHardemanHardinHawkinsHaywoodHendersonHenryHickmanHoustonHumphreysJacksonJeffersonJohnsonKnoxLakeLauderdaleLawrenceLewisLincolnLoudonMaconMadisonMarionMarshallMauryMcMinnMcNairyMeigsMonroeMontgomeryMooreMorganObionOvertonPerryPickettPolkPutnamRheaRoaneRobertsonRutherfordScottSequatchieSevierShelbySmithStewartSullivanSumnerTiptonTrousdaleUnicoiUnionVan BurenWarrenWashingtonWayneWeakleyWhiteWilliamsonWilsonHousing Status(Required)HousedUnhousedOtherHealth Insurance(Required)InsuredNot insuredNot surePossible ways you may have contracted HIV(Required)Check as many as applicable. No risk identified Injecting substances Snorting substances Multiple sex partners Previous and/or recent positive test result for another sexually transmitted infection (STI) Sex with someone who has HIV Sex with men Sex with women Sex with other genders Previous HIV test result(Required)I have never been tested for HIVI have been tested for HIV and tested negativeI have been tested for HIV and tested positiveHow recent was your potential exposure?(Required)Within the last 72 hoursMore than 72 hours agoUnsureIf your most recent exposure was within 72 hours, post-exposure medication is available. Please call us at 865-525-1540 or visit your nearest emergency room.Please read and check the box next to each statement to request your at-home HIV test kit(Required) I understand that my agreement to be tested is voluntary. I understand that there is some level of risk that information in test messaging could be read by someone other than myself. I understand that HIV is reportable by the state of Tennessee and that positive test results will be reported to the local health department. I understand that there is a period of up to 90 days after exposure, and it is recommended to retest if a negative result is received before the 90-day window. I understand that antibodies are the body’s reaction to foreign substances, and that this test is approximately 98% accurate if taken 90 days after exposure. I understand that if my test result is reactive/positive, further testing will need to be performed for confirmation. I understand that I will receive follow-up text messages from a prevention team member to report my test result. By typing my name and the date below, I verify my consent for Positively Living & Choice Health Network to mail an at-home HIV test kit to the address provided above.Full Name(Required)Date(Required) Month Day Year
