Sexual Health Screening Request Use to request an HIV, Hepatitis or Syphilis blood test, or Chlamydia & Gonococcal self-test kits. Non-urgent advice:Check, is this an emergency? For the form to appear, please click to confirm you have read the emergency information:When to call 999Please note, this form cannot be used to request emergency contraception at this time. Have you read "When to call 999"? Yes No How to use this form Use instead of phoning to contact us about your sexual health. We aim to respond by the end of the next working day. Your form is sent to us securely and processed by one of our admin staff. We may need to call you so please give us a working telephone number. You can also get direct support from Sexual Health Sheffield About YouYour Full Name First Name Surname Your Date Of Birth Day Month Year This field is hidden when viewing the formAge OptionalAddress Street Address ZIP / Postal Code Your Contact NumberWe will call back during practice opening hours by the end of the following working day. We DO NOT enter into email conversations. Your Email Address This is only for us to contact you if we cannot get hold of you by telephone and if we feel we need to contact you. About you and your genderWhich gender do you most identify with? Female Male Transgender, born male, now living as female Transgender, born female, now living as male Non-binary Prefer not to say Other This form is secure. Your response is added by the practice to your private medical records.About your sexualitySexual Partners I don’t currently have a sexual partner I have one current sexual partner I have more than one current sexual partner How would you describe your sexuality? I might choose a MALE partner I might choose a FEMALE partner I might choose a partner who does not identify with a specific gender Prefer not to say Choose as many as might applyHow would you describe your sexuality? My partner is MALE My partner is FEMALE My partner does not identify with a gender Prefer not to say How would you describe your sexuality? I have sex with WOMEN I have sex with MEN I have sex with BOTH men and women I have sex with people who do not identify with a gender Prefer not to say Choose as many as may apply for you.How can we help?What would you like to do? Arrange a BLOOD TEST for HIV infection, Hepatitis and Syphilis Arrange a URINE KIT for Chlamydia and Gonorrhoea infections testing Arrange an appointment with a healthcare professional to discuss my sexual health and testing Request condoms (You can pick more than one)What would you like to do? Arrange a BLOOD TEST for HIV infection, Hepatitis and Syphilis Arrange a VAGINAL SELF SWAB kit for Chlamydia and Gonorrhoea testing Arrange an appointment with a healthcare professional to discuss my sexual health and testing Request condoms (You can pick more than one)What would you like to do? Arrange a BLOOD TEST for HIV infection, Hepatitis and Syphilis Arrange a URINE KIT for Chlamydia and Gonorrhoea infections testing (for people with a penis) Arrange a VAGINAL SELF SWAB kit for Chlamydia and Gonorrhoea testing (for people with a vagina or front hole) Arrange an appointment with a healthcare professional to discuss my sexual health and testing Request condoms (You can pick more than one)Safety & FeedbackI confirm that I understand the following statements: I am the patient. I should call 999 if I am urgently worried about this matter or 111 for more advice. I can also call the medical centre on 0114 239 6687. Have you found this service useful? OptionalPlease Select…5 ☆☆☆☆☆4 ☆☆☆☆3 ☆☆☆2 ☆☆1 ☆Help us to Improve this form. Why not five stars? OptionalName OptionalThis field is for validation purposes and should be left unchanged.