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
First Name *
Last Name *
Date of Birth *
Address *
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Cell Phone Number *
May we text you your appointment information? *
Alternate phone number
Have you been tested at BNHC Before?
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Preferred Language
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Are you homeless?
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Reason for test?
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Will this be your first COVID 19 test?
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Are you employed in healthcare?
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Are you pregnant?
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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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