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First Name
Last Name:
Email:
Phone:
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Birth Date:


"I am HIV+ and would like to Sign Up for a CareXO account"         

"I tested positive for HIV on this date (leave empty if uncertain)" (The date is not required, we will just fill in the present date if unknown)
          
What kind of test do you plan to take? (Select all that apply for this appointment):
HIV (BLOOD)
HIV (RAPID)
HPV
CHLAMYDIA
GONORRHEA
SYPHILIS
HIV (NAAT)
HEPATITIS C
HERPES
 

Step 1 and 2 complete. Please send me a confirmation email to the above address.
(Note: You will not be able to edit your information until after you have taken your test!)

 

 

 

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