Covid-19 Test Requests Facilitate for Hudson Valley Contractors Association

Name*
First Last
Date of birth*
MM slash DD slash YYYY
Email
Cell Phone Number*
Home address*
Street Address City State ZIP Code
Are you requesting this test before your travel or for your return to New York?*
- Need test before my travel
- Need for my return to New York
- Both, need test before my travel and upon my return
Departure date*
MM slash DD slash YYYY

What date are you leaving for your trip?
Return date*
MM slash DD slash YYYY

What date are you returning from your trip?
Consent*
I understand and agree.
I understand that I will take a Covid-19 Test at the Middletown Medical location in Newburgh NY (47 N Plank Rd Suite 19 · In Mid Valley Mall).
The cost of each test is $110 using this program. It is recommended before you travel and when you return.
I understand that the office is closed on Sunday and I will take this into consideration before requesting an appointment so that I get my results before my trip.
I understand that it may take up to 48 hours for test results.
I understand that the information provided in this form will be shared with Middletown Medical.
I understand by completing this form and submitting my personal health information that I am requesting a Covid-19 test.
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