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Book a Rapid Test
Before we contact you to arrange a rapid HIV & Syphilis test we will require some basic information.
Name (you can use fake name if necessary)
*
Please enter a value
Contact Number:
Your e-mail address:
Please enter a valid email address
Are you:
-- Please Select --
Male (including trans men)
Female (including trans women)
Non-Binary, Agender, Gender Fluid, Other
Do you currently or have you ever considered yourself as trans:
-- Please Select --
Yes
No
Not Sure
Do you identify as the following:
-- Please Select --
Gay man
Man who has Sex with Men
Bisexual
Gay woman / Lesbian
Heterosexual / Straight
Unsure / Other
Are you giving us permission to contact you via:
*
Please tick a checkbox
E-mail
Text
Call
Voicemail
Where would you most likely be able to attend a rapid test?
Belfast
Derry/Londonderry
Newry
Would a morning, afternoon or evening appointment suit best?
Morning (10am-12pm)
Afternoon (2PM-5PM)
Evening (5PM-8PM)
Why are you needing a rapid test?
Regular check-up
I have a concern about my or my partner’s sexual health
Entering/Exiting a Relationship
Issues accessing GUM or other testing services
Any other details that may be relevant?
Send
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