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, we will verify your address to confirm it is within our service area. If the request is for someone residing in Barry or Eaton County, an at home STI kit will be mailed within 5 days. Requests to ship outside of the Barry-Eaton jurisdiction will not be fulfilled. Individuals not residing in Barry or Eaton County seeking STI testing should refer to their local health department website: https://www.michigan.gov/mdhhs/inside-mdhhs/county-offices/lhd.

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
Which county are you a resident of? *

Which county are you a resident of? Barry Eaton
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