"*" indicates required fields Step 1 of 12 8% Ok, lets start!......Do you live in West Sussex?Please choose...YesNoWe are sorry, this service is only available for residents of West SussexWe can still see you in clinic though! Please call 01903 285199 to make an appointment Date of Birth*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Your age*Please choose...13-15 Years old16-17 Years oldI am over 18You may need to speak with a nurse before you can be tested. Please call 0800 0150 503 How would you describe your gender*Please choose...Male (including trans man)Female (including trans female)Non-binaryOther (not listed)Is this the gender you were born with*Please choose...YesNoWho do you have sex with?*Please choose....MenWomenMen & Women AssessmentDo you have any of the following?* I do not have any symptoms Unusual discharge Rash or spots on or around your genitals (penis, testicles, vagina or bottom) Lumps or bumps on or around your genitals Sores of ulcers on or around your genitals Bleeding or spotting Genital pain Pain when you pee As you have said Yes to having symptoms, please call 01903 285199 to book an appointment to be seen in clinic (unless you have been advised to continue) Have you had sex with someone in the past 2 weeks who told you they have an STI in the past 2 weeks?*Please choose....YesNoAs you have been in recent contact with a partner who has an STI, we want to see you in clinic, please call 01903 285199 to make an appointment (unless you have been advised to continue) What is your HIV status?*Please choose....Negative (I do not have HIV)Positive (I am HIV+)Don't knowThe only way to find out if you have HIV is to have an HIV test, as symptoms of HIV may not appear for many years. Anyone who thinks they could have HIV should get tested. The earlier it's diagnosed, the earlier you can start treatment and avoid becoming seriously ill. https://www.nhs.uk/conditions/hiv-and-aids/causes/Have you been diagnosed with syphilis before?*Please choose....YesNoThe Online syphilis test does not show new infection for those who have previously had syphilis. If you are concerned you may have been exposed to syphilis recently, you should attend clinic to be tested. Call 01903285199 to book an appointment for a blood test Have you been vaccinated against Hepatitis A?*Please choose....YesNoUnsureTo find out more about Hepatitis A and who need to be vaccinated, visit https://www.nhs.uk/conditions/hepatitis-a/. If you think you might need a vaccination, call 01903285199 to make an appointmentHave you been vaccinated against Hepatitis B?*Please choose....YesNoUnsureTo find out more about Hepatitis B and who need to be vaccinated, visit https://www.nhs.uk/conditions/hepatitis-b/. If you think you might need a vaccination, call 01903285199 to make an appointment Have you been vaccinated against HPV?*Please choose....YesNoUnsureTo find out more about the HPV vaccine and who needs to be vaccinated, visit https://www.nhs.uk/conditions/vaccinations/who-should-have-hpv-cervical-cancer-cervarix-gardasil-vaccine/ . If you think you might need a vaccination, call 01903285199 to make an appointment Are you taking HIV PrEP?*Please choose....YesNoTo find out more about HIV PrEP, and who needs to consider taking it, visit https://www.iwantprepnow.co.uk/ For more information on whether PrEP is for you, check out https://www.iwantprepnow.co.uk/prep-tool/. If you want to discuss starting PrEP with a clinician, call 01903285199 to book an appointment When was the last time you had unprotected (condomless) sex?*Please choose....Less than 72 hoursMore than 72 hours, less than 2 weeksMore than 2 weeks, less than 12 weeksMore than 12 weeksNeverEmergency ContraceptionIf you have a uterus and are not using any other form of contraception you may be at risk of pregnancy. Emergency contraception can be used to reduce the risk of unwanted pregnancy. If the unprotected sex was up to 120 hours ago (5 days), you can access emergency contraception pills from community pharmacy, your GP or sexual health services, or you could have an IUD (coil) fitted in sexual health services and some GPs.To discuss emergency contraception from Sexual Health West Sussex you can book an appointment Click here for more information or phone 01903 285199.STI RiskIf you are testing because you have had sex with someone new or you have a specific concern, please read the following information about window periods (When best to test):If you think you have been exposed to HIV and need Post Exposure Prophylaxis (PEP), following a risk in the past 72 hours call us on 01903 285199 to book an appointment. If you're not sure and want to find out whether you need PEP click here Chlamydia and Gonorrhoea may take up to 2 weeks to show up after infectionHIV may take up to 45 days (6 1/2 weeks) to show up after infectionSyphilis and Hepatitis B may take up to 12 weeks to show up after infectionEmergency ContraceptionIf you have a uterus and are not using any other form of contraception you may be at risk of pregnancy. Emergency contraception can be used to reduce the risk of unwanted pregnancy. If the unprotected sex was up to 120 hours ago (5 days), you can access emergency contraception pills from community pharmacy, your GP or sexual health services, or you could have an IUD (coil) fitted in sexual health services and some GPs.To discuss emergency contraception from Sexual Health West Sussex you can book an appointment Click here for more information or phone 01903 285199.STI RiskIf you are testing because you have had sex with someone new or you have a specific concern, please read the following information about window periods (When best to test):Chlamydia and Gonorrhoea may take up to 2 weeks to show up after infectionHIV may take up to 45 days (6 1/2 weeks) to show up after infectionSyphilis and Hepatitis B may take up to 12 weeks to show up after infectionSTI RiskIf you are testing because you have had sex with someone new or you have a specific concern, please read the following information about window periods (When best to test):HIV may take up to 45 days (6 1/2 weeks) to show up after infectionSyphilis and Hepatitis B may take up to 12 weeks to show up after infection Since your last test have you?Been made to feel hurt, scared or controlled by a partner?*Please choose...YesNoBeen forced or pressured to have sex you didn't want?*Please choose...YesNoHad sex in exchange for money, gifts or drugs & alcohol?*Please choose...YesNoFelt worried a partner may have exposed you to HIV or Hepatitis C?*Please choose...YesNoUsed drugs before sex?*Please choose...YesNoDrunk alcohol before sex?*Please choose...YesNoSelf harmed or hurt yourself intentionally?*Please choose...YesNoSent or received sexual pictures or messages (Sexting) ?*Please choose...YesNoHad sex with someone more than four years older than you?*Please choose...YesNoHad sex with someone who is in a position of trust (police, NHS, social services, counsellor or youth worker, care or support worker, religious or community leader)*Please choose...YesNoGone missing from home or care?*Please choose...YesNoDo you see (or have been referred to) a social worker, counsellor or CAMHS worker?*Please choose...YesNoA member of the team may call you for a discreet chat to check how you are and if there is any other help or support that may help. For information or support on local services that can help, go to: https://www.westsussexwellbeing.org.uk/about-us Your address details (so we can send you the kit)Your First Name* Your Last Name* House/Flat Number or Name* 1st Line of Your Address* 2nd Line of Your Address County* Your Postcode* Your contact detailsYour mobile number (so we can tell you your results)* Confirm your number* Email Enter Email Confirm Email About youYour Country of Birth*Please choose...United KingdomAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsYour ethnic origin*Please choose...White BritishWhite IrishOther WhiteWhite & Black CaribbeanWhite & Black AfricanWhite & AsianOther mixedIndianPakistaniBangladeshiOther AsianCaribbeanAfricanOther BlackChineseAny otherDecline to answer Choose an STI testing pack......Which testing pack do you require? Vaginal Pack (Women who have sex with either: Men, Women or Both) Penis Pack (Men who only have sex with Women) Vaginal Plus Pack (Female sex workers, Trans men, Non -binary people born female) Penis Plus Pack - Men who have sex with either men or men & women, Trans women, Non-binary born male) Any other information we might need to know.... How did you hear about us?How did you hear about us?* Social Media Word of mouth Internet search My GP Nurse/Doctor at Sexual Health Other Consent* I agree to the privacy policy.What do we do with this information? The information you have provided will enable us to send the STI pack to you and register you on our system The information will be stored on our Sexual Health system and will NOT be available to any other health care provider, including your GP. We will not ordinarily share your information outside of our service We will not ordinarily share your information with anyone other than you. In exceptional circumstances, if we have concerns about your safety or others around you, we may contact other health and social care agencies. We will always seek your consent to do this in the first instance, however, if you do not respond to our attempts to contact you, we may proceed without your prior consent. The information will be used anonymously for mandatory statutory reporting We are part of the NHS and are fully compliant with the NHS Act 2006, the Health and Social Care Act 2012, the Data Protection Act, and the Human Rights Act. More information can be found here https://www.england.nhs.uk/ig/about/ & https://www.nhsx.nhs.uk/information-governance/ By ticking the box below you are consenting to use your information to process your test.
