Vamos Bien Brief Questionnaire No.1

How can we best serve you?

Question Title

* 1. Please provide your name and contact information in the space provided below.

Name

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Cell

Phone Number

Question Title

* 2. Are you interested in receiving PrEP?

Yes

No

Question Title

* 3. Do you want us to contact you to schedule an appointment?

Yes

No

Question Title

* 4. What's the best way contact you?

Phone

Cell

Email

Question Title

* 5. Are you interested in receiving an HIV test?

Yes

No

Question Title

* 6. Are you interested in receiving testing for sexually transmitted infections?

Yes

No

Question Title

* 7. Are you interested in receiving a COVID-19 test?

Yes

No

Question Title

* 8. Anything else we should know to best serve you? If so, please write your response in the text box below.

THANK YOU!