HIV Test Form and Mailing Envelope

Order Form

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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.