HIV Test Request – Northeast Health District

Please use this form to request someone to contact you regarding a free, confidential HIV test and discuss the best option (in-clinic or at home testing) for you.

This service is limited to our 10-county service area (Barrow, Clarke, Elbert, Greene, Jackson, Madison, Morgan, Oconee, Oglethorpe and Walton counties).

Someone will reach out to you via phone or email for the next step.

HIV Test Referral

Your FULL Name *

Please enter your full name - First and Last

Your Phone Number

Please be sure to enter a phone number OR an email address in order for us to contact you.

Email Address

Please be sure to enter a phone number OR an email address in order for us to contact you.

COUNTY *

This service is limited to our 10-county service area only at this time.

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