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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 999

Please note, this form cannot be used to request
emergency contraception at this time.
Have you read "When to call 999"?

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 You

Your Full Name
Your Date Of Birth
This field is hidden when viewing the form
Address
We will call back during practice opening hours by the end of the following working day. We DO NOT enter into email conversations.
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 gender

Which gender do you most identify with?

This form is secure. Your response is added by the practice to your private medical records.

About your sexuality

Sexual Partners
How would you describe your sexuality?
Choose as many as might apply
How would you describe your sexuality?
How would you describe your sexuality?
Choose as many as may apply for you.

How can we help?

What would you like to do?
(You can pick more than one)
What would you like to do?
(You can pick more than one)
What would you like to do?
(You can pick more than one)

Safety & Feedback

I confirm that I understand the following statements:
This field is for validation purposes and should be left unchanged.

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