New Organization Onboarding Form - Progressive Diagnostics

COVID-19 Testing New Organization Enrollment Form

Please provide as much information as possible in order to help us provide you with an individualized testing program. Thank you!

Basic Information

Name of Organization *

Address *

Phone *

Email *

Estimated number of individuals to be tested *

Ordering Provider *

Please enter the name of your organization's ordering provider. This is usually the Medical Director, APRN, or equivalent, as decided by your organization.

Provider NPI *

NPI Lookup

No Ordering Provider

We do not have an ordering provider.

Do you have multiple locations within your organization? *

Contacts

Primary Contact *

Primary Contact Phone *

Primary Contact Email *

Positive Results Contact *

Positive Results Phone *

Positive Results Email *

On-Site Contact *

On-Site Contact Phone *

On-Site Contact Email *

Save Progress and Get Link To Resume Later

Basic Information

Contacts

Location Information

Please be advised: All locations are closed on January 1st.

Holiday Hours on Monday, January 2nd will vary by location

Please be advised: All locations are closed on December 25th.

Holiday Hours on Monday, December 26th will vary by location