opening minds. growing pride

Thank you for requesting a test!

Phoenix Center Logo - Central Illinois LGBT Center

HIV Home Test Request

Complete this form to request a free HIV home test kit be sent to you.

Name(Required)
Address (ILLINOIS ONLY)(Required)
MM slash DD slash YYYY
Verification(Required)
I acknowledge that by clicking "submit" I agree to complete a follow-up survey, including my test results, that will be sent to me via email or text (select your preference above).
This field is for validation purposes and should be left unchanged.