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Know The Facts
Get Tested
Get Treated
Condoms
HIV Prevention
Providers Corner
Calendar

Request Our Services

Community Request Form

Disclaimer: Please allow a minimum of 4 weeks advanced notice for all requests.

Date of Request:

Date of Event:*

Beginning time - End time of event:*

Name of Agency:*

Type of Agency:

Address:

Phone number:*

Email:*

Contact Person:*

Requested Services:

STD/HIV Education (General Population) STD/HIV Testing Educational Session (Indicate Gender) Health Fair (Educational Table) Session for Men Only Session for Women Only

Event Details

Event Description:*

Location of Event:*

Number of people expected:

Please Describe Target Population (by Gender, Race/Ethnicity, Age):

Will there be other service providers at the event ?:*

Yes No

Language:

English Creole Spanish

Materials needed:

Condoms Brochures Other

Restrictions (e.g. no condoms, no sexual content images):

AV Equipment:

Yes No

Site Accomodations (for Testing and Health Fair only)

Room near a Bathroom:

Yes No

Private area for Confidential Screening/Testing:

Yes No

Tents/Tables/Chairs will be provided:

Yes No

Space for Mobile Unit(s):

Yes No

How many Mobile Units requested:

1 2 3 4 5

How did you hear about us?:*

Event Google search Healthcare provider Friend Other

Other, please specify source:*

Comments:

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1350 NW 14th Street, Suite 202B
Miami, FL 33125
305-643-7420
Test.Miami@flhealth.gov
testmiami.org

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Request Our Services

Disclaimer: Please allow a minimum of 4 weeks advanced notice for all requests.

Event Details

Site Accomodations (for Testing and Health Fair only)

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