BNHC COVID Appointment Request
Welcome to the Brockton Neighborhood Health Center COVID Appointment Request!

Once this form has been filled out, you will be contacted by our staff and given an appointment at one of our locations. Please do not arrive until you have received your appointment.

Also note that this is only monitored during BNHC business hours and all after hour requests will be completed the following business day.

Please note that we will contact any patient that tests positive, but we will be mailing negative results or you can access your results online at https://myquest.questdiagnostics.com/web/home
First Name *
Last Name *
Date of Birth *
MM
/
DD
/
YYYY
Address *
Gender
Clear selection
Cell Phone Number *
May we text you your appointment information? *
Alternate phone number
Have you been tested at BNHC Before?
Clear selection
Preferred Language
Race
Clear selection
Ethnicity
Clear selection
Are you homeless?
Clear selection
Reason for test?
Clear selection
Will this be your first COVID 19 test?
Clear selection
Are you employed in healthcare?
Clear selection
Are you pregnant?
Clear selection
We will contact you with your appointment information as soon as possible! Again, please do not arrive before you have been assigned an appointment location, date and time. *
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