Patient Registration - Progressive Diagnostics

SCHEDULE YOUR TEST

SAME DAY PCR RESULTS

*Same day if tested by 12pm • Next day if tested after 12pm
*Samples collected on Saturday or Sunday are reported Monday

Please follow these quick and easy steps to book an appointment at your desired location.

Affiliation - Step 1 of 4

Do you have a group or location code? *

Affiliation Code *

Enter Group/Location Code
If this field is pre-filled do not delete it. This is not your insurance group number. This code may also be used if you have not registered in advance of showing up for testing.

Success!

Invalid Code. Please try again or contact us at 888.503.8803 opt. 2 for assistance.

Are you a union member and if so, what union? *

AFM
DGA
IATSE
SAG-AFTRA
Non-Union

What is your parking spot number? *

Town of Westport: Department *

Town of Westport: Testing Reason *

Symptomatic testing at EMS (as needed)
Weekly surveillance testing at Town Hall (scheduled)

Please contact Marc Hartog at 203-341-6056 if you are unsure about which option to select.

Town of Shelton: Department *

Trumbull COVID-19 Popup Testing Event *

The popup testing event is being held on Sat. April 24th at Middlebrook School. Please continue through to the booking page in order to secure your time slot.

Town of Trumbull: Department *

Please select the department that you or your family member works in.

Diocese Schools: Ordering Provider *

MyCatholicDoctor: Ordering Provider *

Coastal Orthopedics: Location *

Coastal Orthopedics: Ordering Provider *

Southwest Connecticut Surgery Center: Ordering Provider *

Coastal Orthopedics: Prescription Upload

Urology Associates of Norwalk: Ordering Provider *

Ordering Provider *

Please enter your ordering provider's full name and phone number.

Are you part of any of the following groups that test with MyCatholicDoctor? *

Malta House
No, this does not apply to me.

Do I need a group code to schedule a test? No. If you are not part of a group, please select "No" and follow the quick and easy steps to schedule your test at one of our Patient Service Centers.

What is a group code and why is it important? A group code a six-character code (two letters, followed by four numbers) assigned to organizations that have partnered with Progressive Diagnostics for testing services. This code helps to determine your testing location, ordering provider and method of payment. You can locate this code on any test kits that were distributed to your group. If you believe you have one but do not know what it is, please call 888.503.8803 opt 2.

Are you currently experiencing any COVID-19 symptoms? *

Select "Yes" if you are currently experiencing any of the following COVID-19 symptoms: Fever between 100.4° F and 102° F, feeling feverish, or feel warm to the touch; shortness of breath, a new or worsening cough, or a sore throat; flu-like symptoms (chills, runny or stuffy nose, headache, body aches, and/or feeling tired); new loss of taste or smell; new nausea, vomiting, or diarrhea.

Please select the option that most closely describes the reason you are getting tested. *

I have been asked to get tested by my healthcare provider, public health department, or a contact investigator.
I have been within 6 ft. of a person for at least 15 min. or have been coughed or sneezed on by a person who has been diagnosed with or presumed to have COVID-19.
I am routinely in a place where people reside, meet, or gather in close proximity. This includes assisted-living and healthcare settings, office buildings, workplaces, schools, group homes, homeless shelters, prisons, and detention centers.
Unexposed but require a test for other reasons (e.g., family visiting, etc.)

Are you considered in the high-risk category for COVID-19 infection? *

Select "Yes" if any of the following statements apply to you: I am 65 years of age or older; I have been told by my doctor that I am very overweight or obese; I have a chronic condition (e.g., diabetes, high blood pressure, kidney disease or on dialysis, liver disease, lung disease or asthma, etc.); I have a heart condition (e.g., previous heart attacks, heart failure, etc.); I have a neurological condition that affects my ability to cough (e.g., had a stroke); I am pregnant; I regularly use tobacco or nicotine products (e.g., cigarettes, e-cigarettes, vapes, hookah, etc.); I have a condition that weakens my immune system or makes it harder to fight infections (e.g., AIDS, cancer, lupus, rheumatoid arthritis, solid organ or bone marrow transplant, etc.); I am taking medication that weakens my immune system (e.g., steroids, chemotherapy, immunologics, etc.).

Are you scheduling a test for travel-related purposes? *

Please note that testing for travel-related purposes is not considered medically necessary. By not meeting any of the additional above criteria for medically necessary COVID-19 testing, you will be required to pay for this test out-of-pocket. You will be prompted to submit payment while booking your appointment in the next steps. Refunds will not be issued once payment is processed, except for testing-related errors or cancellations. In the event of a refund being issued, the refunded amount will be the cost of the test minus a credit card processing fee of 3.1%. Thank you.

Acknowledgment of Cash-Pay *

I acknowledge that, given my selections above, I will be paying cash for this test and not using insurance.

These questions have been developed by independent healthcare providers to assist in determining the need for a COVID-19 test based on CDC recommendations. These questions will be reviewed by an independent healthcare provider to determine your need for a test. All questions are required (*) and must be answered before proceeding to schedule your appointment.

High-Risk Disclaimer: If you are experiencing any of the following symptoms, we recommend that you do not delay medical attention and reach out to your healthcare provider as soon as possible. If you feel like you are having a medical emergency, please call 9-1-1. I have a fever of 102° F or higher, OR I have a fever that has lasted longer than 48 hours. I can’t speak in full sentences or do simple activities without feeling short of breath. I am having severe coughing spells, or I am coughing up blood. My lips or face are blue. I have severe and constant pain or pressure in my chest. I feel dizzy, lightheaded, or too weak to stand. I am having slurred speech or seizures. I do not feel like I can stay at home because I feel seriously ill.

Name *

First

Last

Please enter your name exactly as you would like it to appear on your lab report. Do not include your middle initial.

Date of Birth *//

Email *

Confirm Email

Please use a personal email address as .edu and .gov email accounts may be blocked by a firewall.

Phone *

Address *

Address Line 1

City

State / Province / Region

Postal Code

Country

Race/Ethnicity (required by federal law) *

Gender (required by federal law) *

Female
Male

Payment Method *

Insurance
Cash-Pay
Uninsured

Please Note: You will be required to enter payment information on the next page in order to complete your registration.

Please Note: The uninsured option is only applicable to US citizens. If you are not a US citizen, please select cash-pay.

Insurance Carrier *

Other Insurance Carrier *

Enter the name of your insurance carrier here if it is not listed above.

Member ID *

Group Number

Testing Location *

Bridgeport - 238 Jewett Avenue, Bridgeport, CT 06606
Norwalk - 1 Father Conlon Drive, Norwalk, CT 06851
Shelton - 4 Corporate Drive, Suite 198, Shelton, CT 06484
Wilton - 229 Danbury Road, Wilton, CT 06897

We offer PCR testing at all of our locations and antibody testing only at the Bridgeport and Wilton locations.

Please select how many people will be getting tested (in the same car). *

1 (you)
2
3
4
5

You will have to enter the demographic information for each additional person that will be tested. Unless you are paying cash or are uninsured, you will also have to enter the insurance information for each. Fields will populate below based on the number of people selected.

File Uploads

Photo ID

Ins Card Front

Insurance Card Front

Ins Card Back

Insurance Card Back

Guest 1 Details

Guest 1: Name *

First

Last

Guest 1: Date of Birth *//

Date of Birth

Guest 1: Email *

Confirm Email

Guest 1: Phone *

Phone

Guest 1: Address *

Address Line 1

City

State / Province / Region

Postal Code

Country

Guest 1: Race/Ethnicity (required by federal law) *

Race/Ethnicity

Guest 1: Gender (required by federal law) *

Gender

Guest 1: Insurance Carrier *

Insurance Carrier

Guest 1: Other Insurance Carrier *

Other Insurance Carrier: Enter the name of your insurance carrier here if it is not listed above.

Guest 1: Member ID *

Member ID

Guest 1: Group Number

Group Number

File Uploads

Photo ID

Guest 1: Ins Card Front

Insurance Card Front

Guest 1: Ins Card Back

Insurance Card Back

Guest 2 Details

Guest 2: Name *

First

Last

Guest 2: Date of Birth *//

Date of Birth

Guest 2: Email *

Confirm Email

Guest 2: Phone *

Phone

Guest 2: Address *

Address Line 1

City

State / Province / Region

Postal Code

Country

Guest 2: Race/Ethnicity (required by federal law) *

Race/Ethnicity

Guest 2: Gender (required by federal law) *

Gender

Guest 2: Insurance Carrier *

Insurance Carrier

Guest 2: Other Insurance Carrier *

Other Insurance Carrier: Enter the name of your insurance carrier here if it is not listed above.

Guest 2: Member ID *

Member ID

Guest 2: Group Number

Group Number

File Uploads

Photo ID

Guest 2: Ins Card Front

Insurance Card Front

Guest 2: Ins Card Back

Insurance Card Back

Guest 3 Details

Guest 3: Name *

First

Last

Guest 3: Date of Birth *//

Date of Birth

Guest 3: Email *

Confirm Email

Guest 3: Phone *

Phone

Guest 3: Address *

Address Line 1

City

State / Province / Region

Postal Code

Country

Guest 3: Race/Ethnicity (required by federal law) *

Race/Ethnicity

Guest 3: Gender (required by federal law) *

Gender

Guest 3: Insurance Carrier *

Insurance Carrier

Guest 3: Other Insurance Carrier *

Other Insurance Carrier: Enter the name of your insurance carrier here if it is not listed above.

Guest 3: Member ID *

Member ID

Guest 3: Group Number

Group Number

File Uploads

Photo ID

Guest 3: Ins Card Front

Insurance Card Front

Guest 3: Ins Card Back

Insurance Card Back

Guest 4 Details

Guest 4: Name *

First

Last

Guest 4: Date of Birth *//

Date of Birth

Guest 4: Email *

Confirm Email

Guest 4: Phone *

Phone

Guest 4: Address *

Address Line 1

City

State / Province / Region

Postal Code

Country

Guest 4: Race/Ethnicity (required by federal law) *

Race/Ethnicity

Guest 4: Gender (required by federal law) *

Gender

Guest 4: Insurance Carrier *

Insurance Carrier

Guest 4: Other Insurance Carrier *

Other Insurance Carrier: Enter the name of your insurance carrier here if it is not listed above.

Guest 4: Member ID *

Member ID

Guest 4: Group Number

Group Number

File Uploads

Photo ID

Guest 4: Ins Card Front

Insurance Card Front

Guest 4: Ins Card Back

Insurance Card Back

Informed Consent *

I have read and agree to the terms of service listed below and hereby give my informed consent.

TERMS AND CONDITIONS

By the act of booking the following tests I agree to all terms and conditions listed below:

I certify that this test is for myself, or that I am the guardian of a minor below the age of 18 seeking to take this test and that I am completing this enrollment on behalf of the minor.

I understand that, if I do not have an ordering provider, an independent ordering provider will be appointed to determine whether or not the test(s) are appropriate for me. AFC Urgent Care Bridgeport is one of these independent Partners in Care.

I authorize this independent ordering provider, and any collection personnel and the laboratory to conduct collection and testing for COVID-19 through a PCR test or a blood draw.

I am responsible for checking my email for results notification and logging on to my account to view my results when available.

I understand that after receiving my results, I will have the opportunity for a telemedicine consult with the independent ordering provider to answer any questions I may have.

I authorize my test results to be disclosed to the county, state, or to any other governmental entity as may be required by state, local and/or federal health agency in accordance with applicable law.

I acknowledge that a positive test result is an indication that I must self-isolate as directed by CDC recommendations in an effort to avoid infecting others.

I understand that, as with any medical test, there is the potential for a false positive or false negative COVID-19 test result.

If I receive an abnormal result on a COVID-19 PCR Test and have not connected with the independent ordering provider, I understand that I am responsible for following up with my physician for care, diagnosis or medical treatment (or, if I am the parent or legal guardian of a minor who is providing the sample for testing, the minor’s pediatrician).

I voluntarily agree to this testing for COVID-19.

PRIVACY PRACTICES REGARDING HEALTH INFORMATION DISCLOSURE
The ordering provider and the laboratory will abide by all data privacy and other laws that apply to them, including HIPAA. They will use commercially reasonable best efforts to not disclose any individually identifiable health information, except for the following circumstances: to perform the services (including billing for such services); in case of emergency; for the purposes of contact tracing to inform others about their risks; and otherwise as permitted or required by law.

BILLING
The independent ordering provider will bill your insurance company (or yourself, if you selected to pay cash) for any applicable services included in the review and approval of your COVID-19 tests. The laboratory will separately bill your insurance company (or yourself, if you selected to pay cash) for the laboratory test. There is no financial relationship between the independent ordering provider and the laboratory.

DISPUTE RESOLUTION
In the event of any dispute, claim, question or disagreement arising from or relating to this consent, the parties hereto shall use their best efforts to settle the dispute, claim, question, or disagreement. To this effect, the parties shall consult and negotiate with each other in good faith and, recognizing their mutual interests, attempt to reach a just and equitable solution satisfactory to both parties. If the parties do not reach such solution within a period of thirty (30) days, then all disputes shall be resolved by binding arbitration in Connecticut, in accordance with the Commercial Arbitration Rules of the American Arbitration Association (the “AAA”), subject to the limitations herein. Notice of a demand for arbitration shall be filed in writing with the other party hereto and with the AAA. The demand for arbitration shall be made within a reasonable time after the dispute has arisen. The parties agree that one (1) arbitrator shall arbitrate the dispute. The arbitrator shall be selected by the joint agreement of the parties, but if they do not so agree within twenty (20) days after the date of the notice of a demand for arbitration referred to above, the selection shall be made pursuant to the Commercial Arbitration Rules of the AAA from the panels of business arbitrators maintained by the AAA. The decision of the arbitrator shall be made in writing, shall be final, judgment may be entered upon it in any court having jurisdiction thereof. The expenses of arbitration, including reasonable attorneys’ fees and the fees and expenses of the arbitrator, shall be shared equally by the parties.

GOVERNING LAW
All disputes arising out of or relating to this consent shall be governed by Connecticut law regardless of your country of origin, and notwithstanding of any conflicts of law principles.

PREP ACT LIMITATION OF LIABILITY
A new public health act, called the Public Readiness and Emergency Preparedness (PREP) Act, was issued by the Department of Health and Human Services in 2020. The PREP Act limits the legal rights of persons participating in certain covered countermeasures administered by covered entities. Covered countermeasures include testing to diagnose COVID-19, and covered entities include those administering COVID-19 tests. Therefore, the ordering provider and those assisting with supervising or administering this COVID-19 testing are immune from liability for any loss caused, arising out of, relating to, or resulting from administration or use of this COVID-19 test, except for claims involving willful misconduct.

WAIVER AND RELEASE OF LIABILITY
I, for myself and on behalf of my heirs, assigns, personal representatives, and next of kin, and any minor or participant for whom I am consenting, hereby forever release, indemnify, and hold harmless the parties involved in providing this testing, which includes but is not limited to the independent ordering provider and the laboratory, any individual who extended this testing opportunity to me through their employment or relationship to the ordering provider and the laboratory, the property owner, landlord, and/or property manager of the site where testing takes place, any third-party clinicians operating the test collection site, as well as the associated affiliates, owners, investors, officers, and directors of the parties listed above, from liability and claims for damages or injury arising out of or in connection with any aspect of this COVID-19 testing, whether known or unknown, foreseen or unforeseen, except for claims involving willful misconduct.

IMPORTANT: After hitting the submit button below you will be redirected to a scheduling page where you can book your appointment. Do not close your browser and wait for the scheduling page to load. It may take a few seconds. Thank you!

Single PCR Test 2

Single PCR Test 3

Two PCR Tests 2

Three PCR Tests 2

Four PCR Tests 2

Five PCR Tests 2

Total Cost for your Test(s)

$ 0.00

The cash-pay price for a PCR test is $150 per test. After hitting submit, you will be redirected to PayPal to complete your transaction.

Total Cost for your Test(s)

$ 0.00

The cash-pay price for a PCR test is $150 per test. After hitting submit, you will be redirected to PayPal to complete your transaction.

Total Cost for your Test(s)

$ 0.00

The cash-pay price for a PCR test is $150 per test. After hitting submit, you will be redirected to PayPal to complete your transaction.

SCHEDULE YOUR TEST

SAME DAY PCR RESULTS

888.503.8803

888.503.3516

[email protected]

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