Please select from: *

Swab test (to be used by anyone with a vagina)

Urine test (to be used by anyone with a penis)

Name *

First Name

Last Name

If you are OVER 25, please tick if any of the below apply to you. If you are over 25 and do not fall into these categories, please order a test from Sexual Health London: www.shl.uk. *

If you are UNDER 25 years old you can select N/A.

Living with HIV

Temporary accommodation / no fixed abode

Substance misuse

Diagnosed mental health condition

Sex worker

If your partner falls into any of the above categories

N/A

The information you enter into this form will be collected and stored by Via. Please tick the box below to confirm you understand. *

Yes, I understand

Tick the box to confirm you live in the London Borough of Redbridge *

Yes, I live in Redbridge