COVID-19 Test Registration
To register for COVID-19 antibody and RNA tests, you must complete this form in its entirety.

ANY MISSING INFORMATION MAY SIGNIFICANTLY DELAY YOUR ABILITY TO GET TESTED.

Testing takes place at the Plymouth United Church of Christ/Center for Healing & Hope parking lot located at 902 S Main St, Goshen.

Same day registration is only available for those who complete this form and, if applicable, text insurance information before 12:00 noon. Registrations submitted after 12:00 noon will be registered for testing on the next available date.

We are currently testing on Mondays, Tuesdays, Wednesdays and Fridays.
Full name as it appears on your ID *
Gender *
Full address, city, state, zip *
Phone number where you can be reached *
May we text you at this number? *
Date of birth *
Which video calling apps do you have? (Our doctors prefer to use a video call to relay results.) *
What is the best time to contact you? *
May we text you or leave a voice mail regarding your results? (If you answer "no" you will not be eligible for testing and will not receive a testing appointment.) *
Do you have an email address? *
If yes, what is your email address? (if no, enter N/A) *
If you have an email address, would you like to register to view AND PRINT your negative results AND WORK NOTE (IF NEEDED) through the Athena electronic health records portal? If yes, you will receive an email inviting you to register. If your results are positive, a medical provider will call you as soon as the results are in. *
Emergency contact name *
Emergency contact phone *
Would you like a copy of our privacy policy? If yes, please visit our website at www.chhclinics.org. You can view it under the Affordable Healthcare dropdown. *
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