• HIV SELF TESTING PROGRAM

    PARTICIPANT TESTING FORM

  • PARTICIPANT INFORMATION

  • Birthday*
     - -
  • Format: (000) 000-0000.
  • Is it ok to leave a message?*
  • Is it ok to send a text message?*
  • Is it ok to send an email?*
  • Ethnicity*
  • Race*
  • Assigned Sex at Birth*
  • Gender ID*
  • Sex Partners*

  • HIV SELF TESTING TELEHEALTH APPOINTMENT

  • NOTE - If you would like to schedule a telehealth (virtual) call with a Counseling and Testing Specialist to assist you with the testing process, confirm results, or answer questions, call (615) 761-4474.

  • HIV AND HEPATITIS

    RISK ASSESSMENT
  • Please check all that apply:*
  • Are you currently on PrEP*
  • Nashville CARES is providing PrEP NoW (Immediate Access) and PrEP 2-1-1 (Event-Based PreP) today. You can see a PrEP medical provider and receive your first month of medication today at no cost. Would you like to speak to a PrEP Medical Provider*

  • CONSENT TO TEST, TREAT, AND FOLLOW UP

  • By signing below, I have read, understand, and knowingly consent to the following:

    1. Nashville CARES and/or CARES 360 will provide me with a free and confidential HIV/HCV antibody test and a prevention counseling session.

    2. An HIV-/HCV- (negative) result does not require additional testing but may be impacted by recent drug use or sexual activity.

    3. An HIV+ (positive) result must be confirmed by additional testing, which will be collected today before I leave. I understand that Nashville CARES and/or CARES 360 must share all confirmed HIV+/HCV+ (positive) test results and information with the local Health Department and within Nashville CARES and/or CARES 360 to facilitate linkage to contact/linkage care, treatment, support, and partner notification.

    4. Nashville CARES and/or CARES 360 must share all confirmed HIV+/HCV+ (positive) test results and contact/linkage information with the local Health Department and within Nashville CARES and/or CARES 360 in order to facilitate linkage to care, treatment, support, and partner notification.

    5. I will not receive a written HIV test result due to the antibody window period associated with HIV antibody testing.

    6. Medical treatment provided by CARES 360 medical providers or any of its contracted providers is within the scope of the medical provider's practice.

    7. CARES 360 will provide free PrEP samples.

    8. Follow up on today's treatment by CARES 360 and/or NPS Pharmacy.

  • Date*
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