CLICK AND COLLECT - STI/BBV Screening Questionnaire

Thank you for your interest in Click and Collect STI/BBV testing through SHQ.

STI - this tests for Chlamydia and Gonorrhoea, the two most common sexually transmitted infections in our community. Click here for more information. These can be tested using:
Urine sample - you pee in a jar (for people who use their penis for sex)
Vaginal swab - you insert a cotton swab inside vagina (for people who use their vagina for sex)
Anal swab - you insert a cotton swab inside anus (for people who use their anus for sex)
Throat swab - you insert a cotton swab inside your mouth (for people who use their mouth for sex)

BBV - this tests for HIV, Hepatitis B (which are viral infections transmitted through blood) and Syphilis (which is a bacterial infection transmitted through blood, sex and contact with skin sores). Testing for these 3 infections will require a blood test. Click here for information about HIV/Hep B, and here for information about syphilis.

To complete your testing, you can attend an SHQ clinic, or we can provide you with a pathology referral form to take to your nearest pathology provider, where your samples will be collected. Results are usually available within one week, and you will be notified via your nominated contact method.

Please note, this service is for asymptomatic (no symptoms) testing only. If you are experiencing symptoms, you will need to arrange an appointment with a doctor for further assessment. Please contact our Sexual Health Helpline on 9227 6178 (Mon–Fri, 10am–4pm) for further assistance.

This form should take about 5-10 minutes to complete.

Getting Started

What test(s) would you like to arrange through the SHQ Click and Collect service?? *

Sexually Transmitted Infections test (STI test)Blood Borne Virus test (BBV test)

No problem, we can organise this for you! There is a cost of $35 for this service.
First we need to ask you a few personal questions to determine the best type of test and ensure we have a secure way of informing you of the results.

Feel free to read SHQ Privacy Policy to learn more about how we use your information and keep it safe.

PLEASE NOTE: Positive STI or BBV results are routinely and confidentially reported to the WA Health Department, as required by law

Are you happy to proceed with the testing request? *

YesNo

No problem, we understand.

If you'd prefer to book an appointment to see a clinician, you can do so online or by calling 9227 6177.
You can also find more information and resources on our website or by calling the Sexual Health Helpline on 9227 6178.

Thank you for your interest in SHQ.

About You

Do you have a Medicare Card? *

Please provide details: *

If you don’t have Medicare, please note that there may be additional costs for testing charged by the pathology provider (separate from SHQ). We recommend discussing these fees with the provider prior to any testing.

If you have private health insurance, you may be able to claim some reimbursement. Please check with your insurer beforehand.

If you have any questions, please contact the Sexual Health Helpline on 9227 6178.

Are you happy to proceed with the testing request? *

YesNo

Medicare Card Number *

Medicare Card reference number *

Medicare Card expiry date *

First Name (as per Medicare Card) *

Last Name (as per Medicare Card) *

First Name *

Last Name *

Preferred name (if different)

Pronouns

What is your Individual Healthcare Identifier (IHI) number?

An Individual Health Identifier (IHI) is your digital health profile, and it allows our doctors to send electronic prescriptions straight to your phone/email if required. Further information can be found here.

Date of birth *

Age

Because you are under 16, you will need to have a quick chat with an SHQ clinician before we can organise the test/s for you.

Do you still want to proceed with the booking? *

YesNo

No problem, we understand.

If you'd prefer to book an appointment to see a clinician, you can do so online or by calling 9227 6177.
You can also find more information and resources on our website or by calling the Sexual Health Helpline on 9227 6178.

Thank you for your interest in SHQ.

Phone Number *

Email *

Address *

Street address *

Suburb *

State *

Postcode *

Your Gender Identity: *

Your sex assigned at birth: *

Are you currently pregnant? *

YesNo

Indigenous status: *

Sexual History

The following questions relate to your STI and/or BBV test.

The answers you provide will help us determine the most appropriate tests for you.

What body parts do YOU HAVE and use for sex?

I use MY penis for sexI use MY vagina for sex

I use MY anus for sexI use MY mouth for sexOther (please specify)

What body parts does your sexual partner/s have? *

My sexual partner/s have a penisMy sexual partner/s have a vagina

When was the last time you had sex? *

Some STIs and blood-borne viruses can take a little while to show up on a test. If you’ve had sex in the last 2 weeks (for STI tests) or last 3 months (for BBV tests) that you’re worried about, it’s a good idea to come back for another test later, even if these results are negative.

I understand

Have you had any non-professional tattoos or piercings? *

YesNo

Do you, or have you previously injected drugs? *

YesNo

Are you, or have you been a sex worker? *

YesNo

Have you ever been diagnosed with Syphilis? *

YesNo

When was your most recent diagnosis *

Where did you receive treatment? *

Which treatment regime did you receive? *

Once only (2 injections)Every week for 3 weeks (3 x 2 injections)Other (please specify)

STI Testing

Do you have any symptoms that could suggest you have a STI? *

YesNoNot sure

For example, discharge from penis/vagina, painful sex, sores/lumps/bumps around the genital area, burning or stinging wee, etc.

Please note, the Click and Collect service is for asymptomatic (no symptoms) testing only. As you are experiencing symptoms, you will need to arrange an appointment with a doctor for further assessment. Please book an appointment online here or contact our Sexual Health Helpline on 9227 6178 (Mon–Fri, 10am–4pm) for further assistance.

Thank you for your interest in SHQ.

Please note, the Click and Collect service is for asymptomatic (no symptoms) testing only.

If you are not sure if you are experiencing symptoms, you can contact our Sexual Health Helpline on 9227 6178 (Mon–Fri, 10am–4pm) for further assistance. Alternatively, you can book an appointment online to see a doctor for further assessment.

Thank you for your interest in SHQ.

Would you like to arrange a blood test for BBVs as well? *

YesNo

This tests for HIV, Hepatitis B (which are viral infections transmitted through blood) and Syphilis (which is a bacterial infection transmitted through blood, sex and contact with skin sores).

To have these tests completed, you will need to also have your blood sample taken.

Our preferred provider is PathWest. You can find your nearest collection centre here. However, you are welcome to take your form to any pathology service where blood collection is available.

BBV Testing

To have these tests completed, you will need a pathology request form. Once you have your form, you can attend any pathology collection centre to have your blood sample taken.

Our preferred provider is PathWest. You can find your nearest collection centre here. However, you are welcome to take your form to any pathology service where blood collection is available.

I understand

Plan for Results

IF A TEST COMES BACK NEGATIVE (that means no problems), how would you like us to contact you? *

Send me an SMSSend me an EmailDon't contact me, I'll call SHQ (9227 6178) if I want to

IF A TEST COMES BACK POSITIVE, a clinician from SHQ will call you to discuss what the result means, and whether you need treatment and/or further testing.

SHQ will make 3 attempts to reach you over the phone. If we are unable to reach you after 3 attempts, we will send you a message asking you to call us.

How can we contact you if we can't reach you over the phone? *

By SMS and EmailBy SMS and LetterBy Email and Letter

Click and Collect Payment and Confirmation

How would you like to arrange collection of your samples? *

I would like to have a form sent to me, so I can attend my nearest pathology providerI will attend SHQ Northbridge (70 Roe Street, Northbridge)I will attend SHQ Rockingham (4 Civic Boulevard, Rockingham)

How should we send you the pathology request form? *

By SMSBy Email

You will need to attend during clinic opening hours.

There is approximately a 2 business day turnaround time between form submission and sample kits being ready for collection. Please do not attend beforehand without prior notification, as you may be asked to wait.

When do you plan on attending the clinic?Please note that any kits not collected within 2 weeks will be discarded and a new request form will be required after this time.

I confirm that the date selected above is at least two business days from today. I understand that if I attend the clinic before the selected date, I may be turned away if my kit is not yet ready. *

Yes

If you require testing more urgently, please consider selecting electronic pathology form delivery from the options above. Electronic forms can often be delivered to you more quickly than a clinic site collection kit.

Please enter your payment details below.

You must still sign and submit this form once payment has been made for your Click and Collect request to be processed.

Pay

SHQ’s fee for this service is $35. Please note this service is not rebated by Medicare.

Signature *

Clear

By signing above, I confirm that the information provided is accurate and complete to the best of my knowledge.

Date of Completion *

I would like an email confirmation that my form has been received: