Test@Home HIV Self-Test Kit Order Form

Thank you for using the Test@Home program, designed by and for members of the 2SLGBTQQIA+ community.

Fill out this form to have up to 4 free HIV self-test kit(s) mailed to you via Canada Post. Your order will come in discreet packaging from the Community-Based Research Centre. If you prefer to pick up free HIV test(s) in person, please check local availability on our website: www.cbrc.net/test_now_community_edition

If you are Indigenous and would like to receive an HIV self-test as part of a Medicine Bundle visit: www.cbrc.net/medicinebundle

You can use the HIV self-test kits for yourself or give them to people in your social and sexual network. You may want to consider ordering additional HIV self-test kits if this is your first time using one, or so that you can test again later. You can come back anytime to use this form and order more HIV self-tests.

After submitting your order you will be taken to an optional survey to help us learn more about who is using this service. There are roughly ten multiple choice questions in the survey. Your decision to participate or the answers you provide will not impact your HIV self-test order. Thanks for your consideration.

If you have any questions please reach out to us:
Email: buddies@cbrc.net
Toll-free phone or text: (877) 607-2272

Contact Information
Please enter your information including the address you would like your HIV self-test(s) shipped to. Your order will come in discreet packaging from the Community-Based Research Centre. Packages can be sent anywhere within Canada that is served by Canada Post.

We will only use this information to:

ship your order via Canada Post (Details of package contents are not provided to Canada Post.)
contact you if there is a problem with your order
send you a link to an optional survey 2-3 weeks after your order has been shipped. (The survey asks questions about your experience with the Test@Home program. Participation is optional and does not impact your HIV self-test order.)

You will receive shipping updates and a tracking number directly from Canada Post.

Question Title

* Please don't forget your unit/suite number!
You are welcome to use a nickname, alias or fake name.

First Name *

Last Name *

Street name and # *

Unit/suite #

City/Town *

Province *

Postal Code *

Question Title

* This is a reminder to include your unit/suite number.

Thanks, I included it!

I don't have a unit or suite number.

Question Title

* Email Address:

Question Title

* Phone number:
Please enter just numbers, no dashes or spaces.

Question Title

* How many HIV self-test kits do you want?
If you need more than 4 HIV self-test kits, please email buddies@cbrc.net

33% of survey complete.

Test@Home HIV Self-Test Kit Order Form

Question Title

* Please don't forget your unit/suite number! You are welcome to use a nickname, alias or fake name.

Question Title

* This is a reminder to include your unit/suite number.

Question Title

* Email Address:

Question Title

* Phone number: Please enter just numbers, no dashes or spaces.

Question Title

* How many HIV self-test kits do you want?If you need more than 4 HIV self-test kits, please email buddies@cbrc.net

* Please don't forget your unit/suite number!
You are welcome to use a nickname, alias or fake name.

* Phone number:
Please enter just numbers, no dashes or spaces.

* How many HIV self-test kits do you want?
If you need more than 4 HIV self-test kits, please email buddies@cbrc.net