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.

You can use the HIV self-tests for yourself or give them to people in your social and sexual network. You can come back anytime to use this form to order more HIV self-tests.

After submitting your order you will be taken to an optional 2-minute survey to help us learn more about who is using this service. Your decision to participate and the answers you provide are not linked to your name and will not impact your HIV self-test order.

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 an Indigenous person you may be interested to order a Medicine Bundle that includes Indigenous medicines and HIV self-tests: www.cbrc.net/medicinebundle

If you have any questions please reach out to us:
Toll Free Call/Text: 1-877-607-2272
Email: buddies@cbrc.net

Contact Information

Please enter the first name, last name and address you would like us to ship your HIV self-test(s) to. Your order will come in discreet packaging from the Community-Based Research Centre. Packages can be sent anywhere in Canada that is served by Canada Post. Details of the package contents are not provided to Canada Post.

We will only use this information to:

ship your order via Canada Post
contact you if there is a problem with your order
send you an optional evaluation survey 4-6 weeks after your order has been shipped

You will receive shipping updates and a tracking number directly from Canada Post to the email address you provide.

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 *

Address Line 1 *

Address Line 2

City/Town *

Postal Code *

Question Title

* Province/Territory

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

* Can we email you at a later date to offer additional HIV self-tests?

Yes

Question Title

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

50% 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

* Province/Territory

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

* Can we email you at a later date to offer additional HIV self-tests?

Question Title

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