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together.takemehome.org Open in urlscan Pro
18.254.29.142  Public Scan

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URL: https://together.takemehome.org/order/see-if-you-qualify/1
Submission: On July 02 via manual from US — Scanned from DE

Form analysis 1 forms found in the DOM

POST 

<form class="checkout-form" method="post">
  <input type="hidden" name="csrfmiddlewaretoken" value="CcHRhuHiNjmjlTwP64mV3OCa2qPtxGgiG79ME7EiN5WRpT32fmeAMRtKM4nX7bhd" style="font-size: 18px;">
  <div class="form-group justify-content-center">
    <label class="col din2014-demi text-48-48 mb-3" for="id_zip_code">Enter your zip code.</label>
    <div type="col">
      <div class="input-wrapper">
        <input type="text" name="zip_code" maxlength="5" class="responsive-input-text" pattern="[0-9]{5}" title="5 digit zip code" required="" id="id_zip_code" style="font-size: 48px;">
        <label for="id_zip_code" class="placeholder din2014-demi d-flex justify-content-center align-items-center p-0"><span class="required-placeholder">*</span> Please enter the ZIP code where you will be receiving the test kit. </label>
      </div>
    </div>
  </div>
  <div class="submit-form d-flex justify-content-end align-items-center ttmh-nav-buttons">
    <a href="/" class="btn-link">
                  <div class="btn d-flex align-items-center justify-content-center navigation-btn din2014-extra-bold no-text-transform p-2" alt="Previous page">
                    Back
                  </div>
                </a>
    <button class="m-1 ms-3 btn navigation-btn text-white bg-black din2014-extra-bold no-text-transform" type="submit" name="save" alt="continue form"> Next </button>
  </div>
</form>

Text Content

SUPPORT
EN / ES


 * Order a free HIV self-test
   
   TAKES ONLY 3 MINUTES!

 * How it works
   
   STILL HAVE QUESTIONS?

 * Support after I test
   
   UNDERSTANDING YOUR RESULTS

 * FAQ
   
   ALL YOUR QUESTIONS ANSWERED

 * Resources
   
   LOOKING FOR SOMETHING ELSE?

 * About
   
   LEARN ABOUT THIS PROGRAM

 * Privacy policy
   
   WHAT WE DO WITH YOUR INFORMATION

 * Email Us Call Us

1 Eligibility / Zip Code
Enter your zip code.
* Please enter the ZIP code where you will be receiving the test kit.
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Next

Progress: 1 of 5

This service is only available in the U.S., including Puerto Rico. If you’re in
this area and having trouble ordering a kit, contact our customer service at
support@together.takemehome.org or 628-899-4662.

Find testing outside of the U.S.

* Indicates a response is required