MOCHA Testing Appointment Request
MOCHA offers free STI, HIV and Hep C testing. If you need a SAME DAY appointment, we recommend calling 716-541-0674 OR coming to the MOCHA Center for walk-in testing at the following times: Monday-Friday 8:30am-4:30pm, with extended hours until 6:30pm on Tuesdays! The last testing is set 30 minutes before the building closes.
Name
*
First Name
Last Name
Affirmed/Preferred Name
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
My pronouns are:
They/Them
She/Her
He/Him
Other
Have you been tested at MOCHA before?
*
Yes
No
Unsure
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
What days work best for you?
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
What time works best for you?
*
Morning
Afternoon
Evening
Any specific date/time?
-
Month
-
Day
Year
Date
Time
Hour Minutes
AM
PM
AM/PM Option
I will need the following accommodations in order to participate:
American Sign Language (ASL) Interpreter
Wheelchair Access
Large Print Forms
Other
To confirm or reschedule my appointment, please contact me by:
*
Email
Phone Call
Text Message
Submit
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