XPLORE KIT Order Form
Thank you for taking the time to complete the form for your FREE items. Your responses help in funding requests to keep these items accessible for all. 
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NEW INSTI HIV SELF TEST STARTING MARCH 2026!
INSTI HIV Self-Test is a small finger-prick blood sample, and the test looks for antibodies to HIV.  Results appear in about 1 minute.  

Important Note:

The test is very accurate, but it may not detect very recent infections. After a possible exposure, it can take several weeks for antibodies to show up.


(As we start to use these, please feel free to email marinm@kccare.org for any help on how to use the INSTI HIV Self-Test.) 

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First Name *
Last Name *
Phone Number *
123-456-7890
Email Address *
Preferred Method of Contact *
Please select all that apply.
Required
Please select delivery option of kit *
Mailed kits require address for delivery. 
PLEASE NOT:

Due to funding requirements, Xplore Kits are available only to individuals within a specific service radius of KC CARE. Requests submitted outside this area cannot be fulfilled, and you will be contacted if this applies to your request.

We recommend seeking STI/HIV testing services in your local area if you are outside the service region.

Zipcode *
Ex. 64111
Mailing Address
# Street, City, State, Zip Code (to ensure delivery complete all fields) 
Example: 3515 Broadway Apt. 71, Kansas City, MO 64111
Date of Birth *
Date
Gender Identity *
Ethnicity *
Race *
What is your sexual orientation? *
When was your last STI* Test? *
*STI (Sexually Transmitted Infection) test may include: Chlamydia, Gonorrhea, Syphilis, Herpes, Genital Warts, and/or a Hep-C* test. 
Have you ever been tested for HIV? *
If yes, when? *
If you selected "No" to "Have you ever been tested for HIV" please select "Never been tested." 
Are you currently taking daily PrEP medication?
 *
PrEP stands for Pre-Exposure Prophylaxis a daily pill to protect from contracting HIV.
Have you used PrEP anytime in the last 12 months?
 *
Do you want someone to contact you about starting PrEP?
 *
Learn more about PrEP at: https://kccare.org/prep/ 
How often do you use safer sex practices?  *
Safer Sex practices may include condoms, regularly testing, and/or asking sex partner their STI status.
Check which statement applies to you. *
Select all that apply. 
Required
Number of sexual partners in the last 12 months.
 *
In the past 12 months, what of the following apply to you?
 *
Select all that apply.
Required
Select Safer Sex Items
Barrier devices contain rubber latex, which may cause allergic reactions. All safer sex items come with lube.
Was your last sexual encounter at least 3 weeks ago?  *
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