Request HIV, Hepatitis C, and/or STD Testing

Your Name (how you'd like us to refer to you)

Your Email Address

Your mobile phone number

Is English your primary language? If not, we can provide language translation. \ ¿Es el inglés su idioma principal? Si no, podemos proporcionar traducción de idiomas.
Yes \ SiNo \ No

What is your current gender identity?
FemaleMaleNon-binaryGender non-conforming

What was your sex indicated at birth?
FemaleMaleOther

When you have sex, do you have sex with... (check all that apply)?
MenWomenTransgender MenTransgender WomenNonbinary PersonsGender non-conforming persons

Have you ever had sex without a condom?
YesNo

Have you ever shared needles for any purpose?
YesNo

What type of testing are you interested in?
HIVHepatitis CSTD

Are you looking for testing at one of our events? If so, please indicate below.
Hawthorne OfficeKingston OfficeMonticello OfficeMount Vernon OfficeNewburgh OfficePoughkeepsie OfficeSpring Valley OfficeLOFT LGBTQ CenterBard College (testing event)Dutchess Co Pride CenterHudson Valley LGBTQ CenterPace University (testing event)SUNY Orange (testing event)Sullivan Community College (testing event)Vassar College (testing event)Dutchess County Community College (testing event)

Your message (optional)