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(510) - 882 - 2286
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Clinic REGISTRATION FORM
Clinic Days Are Mondays, Wednesdays, & Thursdays, for HIV/STI Testing & Treatment, (12pm-6pm)
& Tuesdays (11am-4pm) for walk-in MPOX vaccine clinic.
For questions, please call our clinic between 12pm-6pm at
510-781-2639
Legal First Name (for insurance purposes)
Legal Last Name
Chosen Name
phone number
Email Address
Which City, State, or Country
Date of Birth
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Have you tested postive for Covid-19 in the last 14 days?
No
Yes
What is your gender identity?
Transgender Woman
Transgender Man
Cis Gender Woman
Cis Gender Man
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What is your sexual orientation?
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Other
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What is your race/ethnicity?
Are you low-income?
No
Yes
Please choose one or more of the following services:
Test/treatment for HIV/STI's/STD's
PEP or PrEP Enrollment
Injectable PrEP
Hormone Injection Assistance
Gender Care Referral
Linkage to primary care
Enrollment in a free or low cost healthcare program
Home HIV/STI Testing
Free Condoms & Lube
Transportation Assistance
Mental Health Support
Dental Care
Housing Assistance
Addiction/Treatment Support
Domestic Violence Support
Formerly Incarcerated - Re-entry Support
Other
Do you have private insurance? If yes, who is your provider?
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