HAPPY Intake Form

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HAPPY Visitor's Information
First
Last
Gender (What do you identify as)? *
Are you Pregnant? *
Other Info (Please check one): *
Do you live in the DC, PG, or Montgomery County area? *
Have you ever been tested for HIV? *
Have you been tested for HIV in the last 3 months? *
If you answered no, would you be interested in getting tested for FREE? If so, Click HERE! *
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