Denton County Public Health | HIV At-Home Self-Test Request

HIV At-Home Self-Test Request

Denton County Public Health
Fields marked with a red asterisk (*) are required.
Denton County Resident
At-home testing through DCPH is only available to individuals who reside in Denton County at this time. If you reside outside Denton County, learn more about testing resources in your area.
Are you a resident of Denton County?*
Personal Information

DCPH does not currently provide at-home testing for individuals under the age of 17.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Age
Sex
Contact Information

DCPH will contact you via phone to verify the details you provided within this form.
Phone Number*
10 Digits only. No dashes or spaces.
Email
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Certification Statement

DCPH will contact you via phone to verify the details you provided within this form.
I certify that I currently reside in Denton County, Texas.*

Agree
At-home testing through DCPH is only available to individuals who reside in Denton County at this time.
If you reside outside Denton County, learn more about testing resources in your area.
Please verify that you are human*
Should be Empty:

HIV At-Home Self-Test Request