Thank you for your interest in this new free HIV self-testing program!

The test you’ll receive in the mail is an OraQuick Oral Antibody test; it is performed by placing a swab on the lining of your mouth. Results take 20 minutes to process. Please complete the below details and click the submit button at the end of the form. If you have any questions, please contact the Florida Department of Health at testing@knowyourhivstatus.com. Please note the program is only available to Florida residents with a Florida address, while supplies last.

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* 1. Are you a Florida resident?

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* 2. Were you referred to this site by a local organization?

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* 3. If yes, please provide name of agency.

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* 4. When were you last tested for HIV?

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* 5. First Name

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* 6. Last Name

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* 7. Phone Number

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* 8. Email

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* 9. Age

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

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* 11. City

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* 12. State (Florida residents only)

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* 13. ZIP Code

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* 14. Country of Birth

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* 15. Please identify your gender

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* 16. Please identify your race/ethnicity

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