New College 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 weekly *

WiFi and Location Details *

Please use this field to provide the following information about this location:
1. WiFi. Network name and password.
2. Entry Requirements and Parking. Where to park, location to check in when they arrive etc.
3. Sample Collection Location. The room number (please make sure it has access to a table, chair, trash bin and power outlet for equipment setup).

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

For Consumers

For Healthcare Providers

About Us

Contact

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Basic Information

Contacts

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