First Name *
Last Name *
Address
City
State —Please choose an option—AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFederated States Of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming
Zip Code
Email Address *
Phone Number *
I’m interested in: (Select all that apply)
HIV testing and treatment
STD testing and treatment
Hepatitis C testing and treatment
PrEP treatment options
(nPEP) I believe I have been recently exposed to HIV within 72 hours
Consultation with a medical provider
Patient Financial Assistance Program
Comment
Life Line Health will not use the information you provide to send unsolicited communications and will not sell your information to any third party.
Connect with a Lifeline Health staff member in-person at your local health center to receive the care you need. You can conveniently make an appointment online to get started.
Thanks for the payment. Your test results will be sent to cristina@gmail.com within a few days.
