Self test kits - 16-17 year olds Personal information Note: Questions marked by * are mandatory *This is a mandatory field. What is your first name *This is a mandatory field. What is your surname? *This is a mandatory field. What is your date of birth? DD 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 MM Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec *This is a mandatory field. What is your gender Male (cis or trans) Female (cis or trans) Non-Binary Rather Not Say *This is a mandatory field. I would describe my ethnic origin as... Please Select An Option White BritishWhite IrishWhite OtherBlack CaribbeanBlack AfricanBlack OtherIndianPakistaniBangladeshiAsian OtherWhite & Black CaribbeanWhite & Black AfricanWhite & AsianMixed OtherChineseAny Other *This is a mandatory field. What is your sexual orientation? Heterosexual / Straight Gay man Lesbian Bi-sexual Other Rather not say You are here: Page 1 of 4
