Kansas Department of Health and Environment: HIV Test Form and Mailing Envelope Order Form

KDHE Home - Health - BDCP - HIV/AIDS Program - HIV Test Form and Mailing Envelope Order Form

HIV Test Form and Mailing Envelope Order Form

All test forms and mailing envelope requests are completed in the order in which they are received. Please allow up to a week for processing.

* Denotes required fields.

* Requested by:

* Facility and Facility ID #:

* Facility mailing address:

* Number of HIV Test Form 1 requested:

* Number of HIV Test Form 2 requested:

* Number of Mailing Envelopes Requested:

Comments or Questions:

Please enter comments or questions here.

Questions: Contact Jamie Flemming at (785) 296-6545 or Fax: (785) 296-4197.