Confidential Form to Request STI Self-Testing

Telehealth visits and self-testing kits are for Clark County, WA residents only. These services are provided free of charge.

Instructions

Complete the form below to request an appointment for a FREE self-testing kit for sexually transmitted infections (STIs). You will be contacted by our program staff within 3 business days to schedule a 20-minute telehealth visit and determine which tests are appropriate for you.

Self-testing kits are only available for residents of Clark County, WA. If you live outside of Clark County and would like to be tested, please leave a voicemail on our confidential line at 564-397-8082. One of our staff members will call you within 1-2 business days to help connect you with services in your area.

People 14 years of age and older can have confidential STI testing and treatment without a guardian(s) consent.

Requirements for telehealth appointment:

A phone, computer, or tablet with access to internet, video, and audio capabilities.
You must be physically in Washington State during the telehealth appointment.
You must have an email to register your self-test kit.

Tests available:

Gonorrhea and Chlamydia*
Syphilis**
HIV*** (P24 antigen & HIV-1/2 antibody test)
Hepatitis C*** (antibody test & viral load)

*Swabs (throat & rectal) and urine sample

**Currently syphilis self-test kits are limited to testing whether the antibody is present in your blood. If antibodies are present, an in-person blood draw is required for additional testing at no cost to you at a public health facility. If you have a history of syphilis, in-person testing is recommended.

***HIV & HCV tests require a small amount of blood from a finger prick.

Currently the self-test kit service we utilize only offers kits in English. We are working on obtaining self-test kits for other languages.

We understand STI testing can be stressful for some. Our staff strive to provide an inclusive and welcoming environment. If you would like to disclose how you talk about your sexual health (certain terminology, past negative experiences, etc.), please do so in the comments so our staff can provide client-centered care.

Our services are protected by HIPAA and are confidential. However, all positive/reactive results are required to be reported to the WA State Health Department (DOH) per state law.

Clark County Public Health

STI/HIV Prevention Program

(564) 397-8082 (Confidential Voicemail)

STDProgram@clark.wa.gov

First Name (Legal or Nonlegal)*

Last Name*

Preferred Name

Date Of Birth*

Assigned Sex at Birth*

Female

Intersex

Male

Gender Identity

Pronouns

Other* (Please enter race below)

Ethnicity*

Hispanic/Latino

Not Hispanic/Latino

Not Sure

Prefer not to say

Preferred Language*

Physical Address*

City, State, & Zip Code*

Mailing Address (If different than physical)

Mailing Address City, State, & Zip

Phone Number*

Phone

Is this a home, work, or cell phone number?*

Select or enter value

Email*

Do you prefer text or email to receive your appointment link?*

Select or enter value

Do you have health insurance? If yes, what kind?*

Medications or Supplements (Name & Dose)?*

Allergies*

Select

Please list the allergy and the reaction you have.*

Other Symptoms (Please describe)

Exposure Date*

Self-testing kits will be mailed 1-3 business days after your scheduled telehealth visit. You do not pay any shipping costs to receive or return the kit.

If you prefer, we can schedule a date and time for you to pick up the kit at our Clark County Public Health Harm Reduction Center. We are located at 1010 Grand Blvd, Vancouver, WA 98661.

Please let us know if you have any privacy concerns with acquiring a kit.

Mail or Pick up?*

Select

Comments

How did you hear about us?*

Select or enter value

Name of Provider/Clinic

Other

Thank you for submitting a self-test kit request. One of our staff members will call you in 1-3 business days. We typically leave a generic voicemail with our name and that we are with Clark County Public Health. We may also send you a text asking you to call us, but please do not respond directly to that text.

Clark County Public Health

STI/HIV Prevention Program

(564) 397-8082 (Confidential Voicemail)

STDProgram@clark.wa.gov

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