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).

A member of our staff 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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Last Updated on June 2, 2022