At-Home Chlamydia & Gonorrhea Test

To request an at-home Chlamydia and Gonorrhea test, you must be 18 or older. Upon the completion of this form, the provide address will be verified.

The test requires a urine sample, which you’ll need to return to the lab using the prepaid postage included in the kit. If your results are positive, a local physician will contact you at no extra cost to discuss treatment options.

Name Name * First Last
Are you +18 years of age? *

Are you +18 years of age? Yes No
Date of Request Date of Request * / MM / DD YYYY
Address Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
I understand if my results are positive a board-certified physician will be in contact for follow-up. *

I understand if my results are positive a board-certified physician will be in contact for follow-up. I understand